Healthcare Provider Details

I. General information

NPI: 1154030252
Provider Name (Legal Business Name): MARYAN MOHAMED SALIM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2022
Last Update Date: 11/17/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1122 GAMMON LN
MADISON WI
53719-2211
US

IV. Provider business mailing address

1122 GAMMON LN
MADISON WI
53719-2211
US

V. Phone/Fax

Practice location:
  • Phone: 504-270-2294
  • Fax:
Mailing address:
  • Phone: 504-270-2294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number0018483
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0018483
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: