Provider Demographics
NPI:1114423886
Name:ATWATER, HALLIE JEAN
Entity Type:Individual
Prefix:
First Name:HALLIE
Middle Name:JEAN
Last Name:ATWATER
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 1:10630 LITTLE PATUXENT PKWY STE 209
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-6278
Mailing Address - Country:US
Mailing Address - Phone:410-456-9593
Mailing Address - Fax:
Practice Address - Street 1:10630 LITTLE PATUXENT PKWY STE 209
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-6278
Practice Address - Country:US
Practice Address - Phone:410-740-8066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD171451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD17145OtherSOCIAL WORK LICENSE NUMBER