=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548895154
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYRANNY SMITH LMSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2020
-----------------------------------------------------
Last Update Date | 03/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 107 E 25TH ST
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21218-5213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-370-8560
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4517 BIRCHWOOD DR
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21229-2490
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-370-8560
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 25511
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------