Basic Information
| Provider Information | |||||||||
| NPI: | 1881620573 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ABDALLAH | ||||||||
| FirstName: | FADI | ||||||||
| MiddleName: | DEEB | ||||||||
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| Credential: | LCSW-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17919 ASHTON CLUB WAY | ||||||||
| Address2: | |||||||||
| City: | ASHTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208619717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017062675 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 CATON AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212295201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103686000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 11908 | MD | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0002348 00 | 05 | MD | MEDICAID |