=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649774456
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL JOSEPH SACO BARGA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2018
-----------------------------------------------------
Last Update Date | 03/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18715 N FREDERICK AVE
-----------------------------------------------------
City | GAITHERSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20879-3121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-364-8453
-----------------------------------------------------
Fax | 301-519-2533
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2117 ELLIS ST
-----------------------------------------------------
City | SILVER SPRING
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20910-1118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-478-0930
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 18949
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------