=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124888656
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAKE IT POSSIBLE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2024
-----------------------------------------------------
Last Update Date | 03/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2255 CRAIN HWY SUITE 202
-----------------------------------------------------
City | WALDORF
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-803-6399
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 440 MONTICELLO AVE STE 1802 PMB 936995
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23510-2670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-803-6399
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | AMARILYS GALLOZA CARRERO
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 757-803-6399
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------