Basic Information
| Provider Information | |||||||||
| NPI: | 1568080745 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAMMER | ||||||||
| FirstName: | NIKOLAI | ||||||||
| MiddleName: | IVANOV | ||||||||
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| Credential: | ADT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 W AYLESBURY RD | ||||||||
| Address2: | |||||||||
| City: | TIMONIUM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210934101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105619591 | ||||||||
| FaxNumber: | 4105619396 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 W AYLESBURY RD | ||||||||
| Address2: | |||||||||
| City: | TIMONIUM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210934101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105619591 | ||||||||
| FaxNumber: | 4105619396 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2020 | ||||||||
| LastUpdateDate: | 07/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | MD | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | 1981 | MD | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.