Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1041C0700X | Clinical Social Worker | 11769 | MD |
NPI | 1003008830 |
---|---|
Provider Name | Ms. Paula Grace |
First Address | Rockville, MD 20852-4908 |
Second Address | Frederick, MD 21703-7314 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/08/2007 |
Last Update Date | 06/12/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
401708100 | (05) | MD |
491631 | (02) | MD |