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General NPI Number Information
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NPI Number | 1770032682
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Entity Type | Individual
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Provider Name | CARRIE BACON
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Gender | Female
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Dates
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Enumeration Date | 10/04/2016
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Last Update Date | 10/04/2016
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Provider Practice Location Address
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Address Line | 1114 BENFIELD BLVD
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City | MILLERSVILLE
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State | MD
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Zip | 21108-2568
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Country | US
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Telephone | 410-780-5203
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Fax | 410-780-5205
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Provider Business Mailing Address
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Address Line | 8967 YELLOW BRICK RD
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City | ROSEDALE
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State | MD
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Zip | 21237-2303
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 14799
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License Number State | MD
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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 | LIC50079475
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License Number State | DC
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