Provider Demographics
NPI:1629632849
Name:FELDER, DEJUAN DWAYNE
Entity Type:Individual
Prefix:
First Name:DEJUAN
Middle Name:DWAYNE
Last Name:FELDER
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 1:1330 SMITH AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-3878
Mailing Address - Country:US
Mailing Address - Phone:410-805-1070
Mailing Address - Fax:
Practice Address - Street 1:1330 SMITH AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-3878
Practice Address - Country:US
Practice Address - Phone:410-805-1070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-23
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1144788316Medicaid