Basic Information
| Provider Information | |||||||||
| NPI: | 1770237786 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONSTANCE W. PULLEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25800 AVONIA LN | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216621417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108226501 | ||||||||
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| Practice Location | |||||||||
| Address1: | 25800 AVONIA LN | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216621417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108226501 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2022 | ||||||||
| LastUpdateDate: | 02/08/2022 | ||||||||
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| AuthorizedOfficialLastName: | PULLEN | ||||||||
| AuthorizedOfficialFirstName: | CONSTANCE | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4108226501 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW-C | ||||||||
| NPICertificationDate: | 02/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 160241100 | 05 | MD | MEDICAID |