=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245253673
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRESCENT PSYCHIATRIC SERVICES, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2006
-----------------------------------------------------
Last Update Date | 09/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2124 RIDING CROP WAY
-----------------------------------------------------
City | WINDSOR MILL
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21244-1287
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-474-1010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2124 RIDING CROP WAY
-----------------------------------------------------
City | WINDSOR MILL
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21244-1287
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-474-1010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MR. YASIN NMN MANSOOR
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 443-474-1010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | D004814
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------