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General NPI Number Information
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NPI Number | 1174925036
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Entity Type | Individual
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Provider Name | TAAVON BAZEMORE JR. LCSW-C
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Gender | Male
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Dates
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Enumeration Date | 09/23/2014
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Last Update Date | 08/23/2023
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Provider Practice Location Address
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Address Line | 421 FALLSWAY
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City | BALTIMORE
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State | MD
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Zip | 21202-4800
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Country | US
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Telephone | 443-703-1196
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Fax |
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Provider Business Mailing Address
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Address Line | 2431 LAKEVIEW AVE APT 3C
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City | BALTIMORE
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State | MD
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Zip | 21217-4709
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Country | US
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Telephone | 443-962-4674
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 18084
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License Number State | MD
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