=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487928388
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THERAPYWORKS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2012
-----------------------------------------------------
Last Update Date | 02/24/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2409 SHELLEYDALE DR
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21209-3209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-358-5882
-----------------------------------------------------
Fax | 443-276-5857
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2409 SHELLEYDALE DR
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21209-3209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-358-5882
-----------------------------------------------------
Fax | 443-276-5857
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | GOLDIE LIEBES
-----------------------------------------------------
Credential | CCC SLP
-----------------------------------------------------
Telephone | 410-358-5882
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 04367
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------