Provider Demographics
NPI:1033647268
Name:BYRD, PAMELA
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:
Last Name:BYRD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19817
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:MD
Mailing Address - Zip Code:21225-0317
Mailing Address - Country:US
Mailing Address - Phone:410-218-9653
Mailing Address - Fax:
Practice Address - Street 1:11 W MOUNT ROYAL AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-5718
Practice Address - Country:US
Practice Address - Phone:410-218-9653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-01
Last Update Date:2017-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC3506101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD419828000Medicaid