MEDICARE: INTERVALS, INC.

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	103TM1800X	Intellectual & Developmental Disabilities Psychologist

General Provider Information

NPI Number	:	1942377593
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERVALS, INC.

Provider Business Mailing Address
First Line	:	4814 SETON DR
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21215-3210
Country	:	US
Telephone Number	:	410-358-6400
Fax Number	:	410-358-6555

Provider Business Practice Location Address
First Line	:	4814 SETON DR
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21215-3210
Country	:	US
Telephone Number	:	410-358-6400
Fax Number	:	410-358-6555

Authorized Official
Title or Position	:	CONTROLLER
Name	:	MR. GARY LANE
Credential	:
Telephone Number	:	410-358-5252

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	08/22/2020

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