=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366101768
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TALBOT CHILD PSYCHOLOGY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2021
-----------------------------------------------------
Last Update Date | 12/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6547 PEACH BLOSSOM HEIGHTS DR
-----------------------------------------------------
City | EASTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21601-4517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 667-662-2219
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8168 ELLIOTT RD STE 1 #1013
-----------------------------------------------------
City | EASTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21601-7111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED SIGNATURE
-----------------------------------------------------
Name | SEAN LOGIE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 667-662-2219
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------