Provider Demographics
NPI:1295045623
Name:EGUDIA, NKEM
Entity Type:Individual
Prefix:
First Name:NKEM
Middle Name:
Last Name:EGUDIA
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 1:2300 GARRISON BLVD STE 230
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21216-2377
Mailing Address - Country:US
Mailing Address - Phone:410-233-4039
Mailing Address - Fax:410-233-4052
Practice Address - Street 1:2300 GARRISON BLVD STE 230
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216-2377
Practice Address - Country:US
Practice Address - Phone:410-233-4039
Practice Address - Fax:410-233-4052
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-19
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD4793251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health