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General NPI Number Information
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NPI Number | 1144402975
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Entity Type | Organization
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Legal Business Name | MALCOM GROW
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Dates
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Enumeration Date | 12/04/2007
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Last Update Date | 12/04/2007
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Provider Practice Location Address
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Address Line | 711 ROMFORD DR
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City | HYATTSVILLE
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State | MD
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Zip | 20785-5940
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Country | US
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Telephone | 301-808-5466
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Fax |
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Provider Business Mailing Address
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Address Line | 503 SPECTATOR AVEUNE
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City | LANDOVER
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State | MD
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Zip | 20785
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Country | US
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Telephone | 301-808-5466
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Fax |
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Authorized Official
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Title or Position | SOCIAL WORKER
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Name | MRS. TRINA LYNN TAYOOR
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Credential |
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Telephone | 301-808-5466
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 276400000X
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Taxonomy Name | Substance Use Disorder Rehabilitation Hospital Unit
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License Number | 612879
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License Number State | MD
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