Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TR0400X | Rehabilitation Psychologist | 210310773 | MD |
N | 103TR0400X | Rehabilitation Psychologist | 210310774 | MD |
NPI | 1699358309 |
---|---|
Provider Name | Mia Matthews |
First Address | Baltimore, MD 21218-3144 |
Second Address | Baltimore, MD 21218-3144 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/04/2021 |
Last Update Date | 30/04/2021 |