Provider Demographics
NPI:1497006589
Name:PRINCE, TANYA Y (MHS, CAC-AD)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:Y
Last Name:PRINCE
Suffix:
Gender:F
Credentials:MHS, CAC-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5620 WESLEY AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21207-6827
Mailing Address - Country:US
Mailing Address - Phone:443-760-2973
Mailing Address - Fax:
Practice Address - Street 1:2225 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-5778
Practice Address - Country:US
Practice Address - Phone:443-573-8673
Practice Address - Fax:410-243-8175
Is Sole Proprietor?:No
Enumeration Date:2012-09-28
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC1790101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDAC1790OtherBOARD LICENSE