Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 08402 | MD |
NPI | 1003414517 |
---|---|
Provider Name | Tracy Gornowski |
First Address | Columbia, MD 21044-5596 |
Second Address | Columbia, MD 21044-5596 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/10/2020 |
Last Update Date | 16/10/2020 |