Healthcare Provider Details

I. General information

NPI: 1588934392
Provider Name (Legal Business Name): MEREDITH RAE ELISEO LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. MEREDITH RAE POLANDO

II. Dates (important events)

Enumeration Date: 01/10/2012
Last Update Date: 01/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6655 FIRST PARK TEN BLVD
SAN ANTONIO TX
78213-4308
US

IV. Provider business mailing address

1407 GRAHAM FARM CIR
SEVERN MD
21144-1086
US

V. Phone/Fax

Practice location:
  • Phone: 210-496-2323
  • Fax:
Mailing address:
  • Phone: 301-814-3019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14050
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: