=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154193753
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MYONNA TERRELLE WASHINGTON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2023
-----------------------------------------------------
Last Update Date | 10/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8416 KAVANAGH RD # 126
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21222-5625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-320-3541
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8416 KAVANAGH RD
-----------------------------------------------------
City | DUNDALK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21222-5625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | W252619789582
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------