Provider Demographics
NPI:1225766579
Name:SOMERVILLE, SIERRA OCTAVIA
Entity Type:Individual
Prefix:
First Name:SIERRA
Middle Name:OCTAVIA
Last Name:SOMERVILLE
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 1:6901 SECURITY BLVD STE 21
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21244-8419
Mailing Address - Country:US
Mailing Address - Phone:410-837-2050
Mailing Address - Fax:
Practice Address - Street 1:6901 SECURITY BLVD STE 21
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21244-8419
Practice Address - Country:US
Practice Address - Phone:410-837-2050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-12
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD273711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical