Provider Demographics
NPI:1629474473
Name:SOMERVILLE, ANTHONY E
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:E
Last Name:SOMERVILLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2866 HILLTOP MALL RD
Mailing Address - Street 2:
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806-2100
Mailing Address - Country:US
Mailing Address - Phone:815-861-8939
Mailing Address - Fax:
Practice Address - Street 1:107 E 25TH ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-5213
Practice Address - Country:US
Practice Address - Phone:815-861-8939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-06
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101Y00000XBehavioral Health & Social Service ProvidersCounselor