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General NPI Number Information
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NPI Number | 1245701713
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Entity Type | Organization
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Legal Business Name | MID ATLANTIC NEUROPSYCHOLOGY LLC
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Dates
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Enumeration Date | 12/10/2018
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Last Update Date | 01/12/2023
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Provider Practice Location Address
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Address Line | 1501 SULGRAVE AVE STE 209
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City | BALTIMORE
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State | MD
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Zip | 21209-3650
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Country | US
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Telephone | 410-205-9820
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Fax |
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Provider Business Mailing Address
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Address Line | 1501 SULGRAVE AVE STE 209
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City | BALTIMORE
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State | MD
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Zip | 21209-3650
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Country | US
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Telephone | 410-205-9820
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | JACOB PRILUCK
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Credential | PSYD
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Telephone | 410-205-9820
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number |
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License Number State |
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