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General NPI Number Information
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NPI Number | 1104003565
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Entity Type | Individual
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Provider Name | LESIA MALKO TRICKETT M.D.
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Gender | Female
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Dates
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Enumeration Date | 01/29/2008
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Last Update Date | 09/13/2013
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Provider Practice Location Address
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Address Line | 3901 GREENSPRING AVE
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City | BALTIMORE
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State | MD
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Zip | 21211-1353
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Country | US
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Telephone | 443-923-5932
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Fax |
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Provider Business Mailing Address
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Address Line | 3901 GREENSPRING AVE
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City | BALTIMORE
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State | MD
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Zip | 21211-1353
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0804X
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Taxonomy Name | Child & Adolescent Psychiatry Physician
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License Number | D0074177
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License Number State | MD
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