=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689097438
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STACEY ERD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2014
-----------------------------------------------------
Last Update Date | 01/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10411 MOTOR CITY DR SUITE 500
-----------------------------------------------------
City | BETHESDA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20817-1008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-337-0954
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12701 STEEPLE CHASE WAY
-----------------------------------------------------
City | POTOMAC
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20854-2343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-424-3909
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | STACEY ERD
-----------------------------------------------------
Credential | MSW
-----------------------------------------------------
Telephone | 307-337-0954
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 17867
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------