Provider Demographics
NPI:1710562665
Name:WARD, RUSTLYN MONICA (MHS)
Entity Type:Individual
Prefix:
First Name:RUSTLYN
Middle Name:MONICA
Last Name:WARD
Suffix:
Gender:F
Credentials:MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4654 YORK RD.
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212
Mailing Address - Country:US
Mailing Address - Phone:410-419-7792
Mailing Address - Fax:
Practice Address - Street 1:5016 NORWOOD AVE
Practice Address - Street 2:4654 YORK RD.
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21207
Practice Address - Country:US
Practice Address - Phone:410-419-7792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-12
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDSC1325101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty