=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578083630
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SYMONE COLQUITT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2017
-----------------------------------------------------
Last Update Date | 06/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7309 BALTIMORE AVE STE 117
-----------------------------------------------------
City | COLLEGE PARK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20740-3200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-213-1755
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1805 CROSBY RD
-----------------------------------------------------
City | HYATTSVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20783-2918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-422-6779
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | LMC402
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------