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General NPI Number Information
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NPI Number | 1669941175
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Entity Type | Organization
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Legal Business Name | MD MATT LLC
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Dates
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Enumeration Date | 11/14/2018
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Last Update Date | 06/24/2024
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Provider Practice Location Address
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Address Line | 10220 S DOLFIELD RD STE 106
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City | OWINGS MILLS
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State | MD
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Zip | 21117-3660
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Country | US
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Telephone | 443-559-4137
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Fax |
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Provider Business Mailing Address
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Address Line | 10220 S DOLFIELD RD STE 106
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City | OWINGS MILLS
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State | MD
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Zip | 21117-3660
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Country | US
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Telephone | 443-559-4137
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Fax |
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Authorized Official
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Title or Position | CARE COORDINATOR
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Name | WILLIAM CORY SHAFFER
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Credential |
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Telephone | 443-559-4137
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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