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General NPI Number Information
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NPI Number | 1205079746
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Entity Type | Organization
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Legal Business Name | COQUUS
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Dates
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Enumeration Date | 04/14/2009
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Last Update Date | 06/24/2009
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Provider Practice Location Address
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Address Line | 21 INDUSTRIAL PARK DR SUITE 202 F
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City | WALDORF
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State | MD
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Zip | 20602-2751
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Country | US
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Telephone | 301-848-0461
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Fax | 301-885-0922
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Provider Business Mailing Address
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Address Line | 21 INDUSTRIAL PARK DR SUITE 202 F
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City | WALDORF
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State | MD
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Zip | 20602-2751
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Country | US
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Telephone | 301-848-0461
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Fax | 301-885-0922
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. PATRICIA VANCE
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Credential | PH.D.
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Telephone | 301-848-0461
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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 | 05567
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 02983
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License Number State | MD
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