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General NPI Number Information
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NPI Number | 1548984404
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Entity Type | Organization
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Legal Business Name | MAGELLAN PROVIDER SERVICES OF CA PC
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Dates
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Enumeration Date | 10/03/2022
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Last Update Date | 10/03/2022
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Provider Practice Location Address
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Address Line | 8621 ROBERT FULTON DR
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City | COLUMBIA
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State | MD
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Zip | 21046-2620
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Country | US
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Telephone | 833-605-0634
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Fax |
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Provider Business Mailing Address
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Address Line | 8621 ROBERT FULTON DR
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City | COLUMBIA
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State | MD
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Zip | 21046-2620
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Country | US
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Telephone | 833-605-0634
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Fax |
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Authorized Official
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Title or Position | CHIEF FINANCIAL OFFICER
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Name | MR. BRIAN FREY
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Credential |
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Telephone | 314-406-8632
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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