Basic Information
| Provider Information | |||||||||
| NPI: | 1417082959 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WASHINGTON COUNTY EARLY INTERVENTION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10435 DOWNSVILLE PIKE | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217401732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017668222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10435 DOWNSVILLE PIKE | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217401732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017668222 | ||||||||
| FaxNumber: | 3017916716 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2007 | ||||||||
| LastUpdateDate: | 09/10/2021 | ||||||||
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| AuthorizedOfficialLastName: | MICHAEL | ||||||||
| AuthorizedOfficialFirstName: | BOYD | ||||||||
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| AuthorizedOfficialTitleorPosition: | SUPERINTENDENT | ||||||||
| AuthorizedOfficialTelephone: | 3017662815 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
| NPICertificationDate: | 09/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 103TS0200X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | School | 224Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225200000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 541448200 | 05 | MD | MEDICAID |