MEDICARE: PSYCHIATRIC NURSE PRACTITIONER ASSOCIATE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	R121391	MD

General Provider Information

NPI Number	:	1184748667
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PSYCHIATRIC NURSE PRACTITIONER ASSOCIATE, LLC

Provider Business Mailing Address
First Line	:	4401 E WEST HWY
Second Line	:	SUITE 206 B
City	:	BETHESDA
State	:	MD
Zip	:	20814-4523
Country	:	US
Telephone Number	:	301-907-6695
Fax Number	:	301-907-6771

Provider Business Practice Location Address
First Line	:	4401 E WEST HWY
Second Line	:	SUITE 206 B
City	:	BETHESDA
State	:	MD
Zip	:	20814-4523
Country	:	US
Telephone Number	:	301-907-6695
Fax Number	:	301-907-6771

Authorized Official
Title or Position	:	PSYCHIATRIC NURSE PRACTITIONER
Name	:	TERESA RICHARDSON
Credential	:	CRNP,BC
Telephone Number	:	301-907-6695

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	06/23/2008

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