Basic Information
| Provider Information | |||||||||
| NPI: | 1275594640 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHESAPEAKE NEUROLOGY AND BEHAVIORAL HEALTH, LLC | ||||||||
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| OtherOrganizationName: | CHESAPEAKE NEUROLOGY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 HOSPITAL RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | PRINCE FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206784015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105352500 | ||||||||
| FaxNumber: | 4105356030 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 HOSPITAL RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | PRINCE FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206784015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105352500 | ||||||||
| FaxNumber: | 4105356030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2006 | ||||||||
| LastUpdateDate: | 01/05/2022 | ||||||||
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| AuthorizedOfficialLastName: | MANN | ||||||||
| AuthorizedOfficialFirstName: | SHEILA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2404178832 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 174400000X | D0042985 | MD | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 754991100 | 05 | MD | MEDICAID |