Healthcare Provider Details

I. General information

NPI: 1144947797
Provider Name (Legal Business Name): PM KIDS PLUS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2022
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 POST OFFICE RD STE 106
WALDORF MD
20602-1914
US

IV. Provider business mailing address

603 POST OFFICE RD STE 106
WALDORF MD
20602-1914
US

V. Phone/Fax

Practice location:
  • Phone: 240-585-7128
  • Fax: 240-607-6749
Mailing address:
  • Phone: 240-585-7128
  • Fax: 240-607-6749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. WALI GAUVIN
Title or Position: CO-OWNER
Credential: MD
Phone: 240-585-7128