=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700848694
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALAN S BELLACK PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2006
-----------------------------------------------------
Last Update Date | 08/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 N GREENE ST VAMHCS, MIRECC/6A
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21201-1524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-695-7383
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 WELLS LNDG
-----------------------------------------------------
City | ANNAPOLIS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21403-2316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-605-7383
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 03178
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------