Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TR0400X | Rehabilitation Psychologist |
NPI | 1669957544 |
---|---|
Provider Name | Tracey Andrea Royster-Bennett |
First Address | Baltimore, MD 21202-1269 |
Second Address | Baltimore, MD 21229-5265 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/09/2018 |
Last Update Date | 26/09/2018 |