=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396385530
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHAEL T. REID, PH.D. LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2020
-----------------------------------------------------
Last Update Date | 01/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1122 KENILWORTH DR STE 100
-----------------------------------------------------
City | TOWSON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21204-2142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-881-3945
-----------------------------------------------------
Fax | 410-881-3945
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1122 KENILWORTH DR STE 100
-----------------------------------------------------
City | TOWSON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21204-2142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-881-3945
-----------------------------------------------------
Fax | 410-881-3945
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | DR. MICHAEL TALBOT REID
-----------------------------------------------------
Credential | PH.D
-----------------------------------------------------
Telephone | 410-698-3006
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------