=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750940185
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHERINE WACHTER MULLINS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2019
-----------------------------------------------------
Last Update Date | 01/31/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 EAST NORTH AVE RELATED SERVICES - RM 210
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-642-4211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 S ELLWOOD AVE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21224-2241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-383-9200
-----------------------------------------------------
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 | 15425
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------