CONSULTATION AND CRISIS INTERVENTION ASSOCIATES, LLC - NPI NUMBER 1518213982

Summary

Provider Name: CONSULTATION AND CRISIS INTERVENTION ASSOCIATES, LLC

NPI Number: 1518213982

Clasification: Clinical Neuropsychologist (103G00000X)

Address:
1107 KENILWORTH DR STE 210
BALTIMORE, MD
ZIP 21204

Phone Number: (410) 296-1880



Detailed Information

CONSULTATION AND CRISIS INTERVENTION ASSOCIATES, LLC is a clinical neuropsychologist in Baltimore, MD. The provider is an individual with a doctorate degree, licensure in clinical psychology and specialized training or board certification in neuropsychology who practices or adheres to the principles of neuropsychology; a specialty within the field of psychology focusing primarily on neurobehavioral functioning. The assigned NPI number for this provider is 1518213982 and is registered as an organization entity type and is a single specialty group.

The provider's business address is:

1107 KENILWORTH DR STE 210
BALTIMORE, MD
ZIP 21204-136
Phone: (410) 296-1880
Fax: (410) 494-0368

The provider's authorized official is Peter Smith .
The authorized official title is Medical Director and has the following contact phone number (410) 296-1880.

The enumeration date for this NPI number is 8/3/2012 and was last updated on 8/3/2012.

Map - Location of Practice

Taxonomy Codes

The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1 103G00000X Clinical Neuropsychologist 04668 MD Yes

NPI Record

No. Field Name Field Value Field Definition 1
1 NPI 1518213982 The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
2 Entity Type Code 2 Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
3 Employer Identification Number EIN The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
4 Provider Organization Name Legal Business Name CONSULTATION AND CRISIS INTERVENTION ASSOCIATES, LLC The name of the organization provider. If the provider is an organization, this is the legal business name.
5 Provider First Line Business Practice Location Address 1107 KENILWORTH DR STE 210 The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
6 Provider Business Practice Location Address City Name BALTIMORE The city name in the location address of the provider being identified.
7 Provider Business Practice Location Address State Name MD The State code in the location of the provider being identified.
8 Provider Business Practice Location Address Postal Code 212042136 The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
9 Provider Business Practice Location Address Country Code If outside U S US The country code in the location address of the provider being identified.
10 Provider Business Practice Location Address Telephone Number 4102961880 The telephone number associated with the location address of the provider being identified.
11 Provider Business Practice Location Address Fax Number 4104940368 The fax number associated with the location address of the provider being identified.
12 Provider Enumeration Date 8/3/2012 The date the provider was assigned a unique identifier (assigned an NPI).
13 Last Update Date 8/3/2012 The date that a record was last updated or changed.
14 Authorized Official Last Name SMITH The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
15 Authorized Official First Name PETER The first name of the authorized official.
16 Authorized Official Title or Position MEDICAL DIRECTOR The title or position of the authorized official.
17 Authorized Official Telephone Number 4102961880 The 10-position telephone number of the authorized official.
18 Healthcare Provider Taxonomy Code 1 103G00000X Code designating the provider type, classification, and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1.
19 Provider License Number 1 04668 The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’.
20 Provider License Number State Code 1 MD The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number.
21 Healthcare Provider Primary Taxonomy Switch 1 Y
22 Is Organization Subpart N
23 Authorized Official Name Prefix Text DR.
24 Authorized Official Credential Text PSYD
25 Healthcare Provider Taxonomy Group 1 193400000X SINGLE SPECIALTY GROUP

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This page was last updated on: 4/19/2015

(1) Field Definition Source-. Federal Register / Vol. 69, No. 15 / Friday, January 23, 2004 / Rules and Regulations - Part II Department of Health and Human Services Office of the Secretary 45 CFR Part 162 HIPAA Administrative Simplification: Standard Unique Health Identifier for Health Care Providers; Final Rule

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