Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. 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 | 1041C0700X | Social Worker | Clinical | | | No |
| 2 | 101YP2500X | Counselor | Professional | | | No |
| 3 | 2084P0800X | Psychiatry & Neurology | Psychiatry | | | No |
| 4 | 103TC0700X | Psychologist | Clinical | | | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | C19816 | OTHER | MARYLAND | RRMEDICARE MCARE |
| 2 | 212838 | MEDICARE PIN | ILLINOIS | |
| 3 | KN18 | MEDICARE PIN | MARYLAND | |
| 4 | 0P45770 REGION 01 | MEDICARE PIN | MICHIGAN | |
| 5 | 116570 | MEDICARE PIN | IOWA | |
| 6 | G396 | OTHER | MARYLAND | BCBS CAREFIRST |
| 7 | 711902 | MEDICARE PIN | NORTH DAKOTA | |
| 8 | C06006 | MEDICARE PIN | VIRGINIA | |
| 9 | 212836 | MEDICARE PIN | ILLINOIS | |
| 10 | DE8053 | OTHER | ILLINOIS | RR MEDICARE 16 ILL |
| 11 | 233310 | MEDICARE PIN | INDIANA | |
| 12 | 212837 | MEDICARE PIN | ILLINOIS | |
| 13 | CG3517 | OTHER | DISTRICT OF COLUMBIA | RR MEDICARE XCARE |
| 14 | BM60T | OTHER | MARYLAND | BCBS |
| 15 | 744L | MEDICARE PIN | MARYLAND | |
| 16 | 11524 | MEDICARE PIN | DISTRICT OF COLUMBIA | |
| 17 | DF3257 | OTHER | IOWA | RR MEDICARE IOWA |
| 18 | DE7999 | OTHER | ILLINOIS | RR MEDICARE 99 IL |
| 19 | CD3552 | OTHER | VIRGINIA | RR MEDICARE VCARE |
| 20 | 0P45760 REGION 99 | MEDICARE PIN | MICHIGAN | |
