MEDICARE: MARYLAND PSYCHIATRY 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1326817164
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARYLAND PSYCHIATRY LLC

Provider Business Mailing Address
First Line	:	4620 FAIT AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21224-4431
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	910 WASHINGTON RD STE D
Second Line	:
City	:	WESTMINSTER
State	:	MD
Zip	:	21157-5845
Country	:	US
Telephone Number	:	443-398-4207
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. ASHLEY VICKERY
Credential	:	CRNP-PMH
Telephone Number	:	443-398-4207

Provider Enumeration Date	:	12/21/2023
Last Update Date	:	12/21/2023

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