Basic Information
| Provider Information | |||||||||
| NPI: | 1295968683 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONWAY | ||||||||
| FirstName: | MONICK | ||||||||
| MiddleName: | NICOLE | ||||||||
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| NameSuffix: | |||||||||
| Credential: | BSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2336 GODDARD PKWY | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218011126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103346961 | ||||||||
| FaxNumber: | 4103346960 | ||||||||
| Practice Location | |||||||||
| Address1: | 29516 CANVASBACK DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | EASTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216017140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108225007 | ||||||||
| FaxNumber: | 4108225569 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2009 | ||||||||
| LastUpdateDate: | 09/01/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 609550002 | 05 | MD | MEDICAID | 499188MD | 01 | MD | VO MHA | OTHER |