=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669957544
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACEY ANDREA ROYSTER-BENNETT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2018
-----------------------------------------------------
Last Update Date | 09/26/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3455 WILKENS AVE STE 203
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21229-5265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-927-5050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 414 LIGHT ST UNIT 1301
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21202-1269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-927-5050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------