Provider Demographics
NPI:1972929099
Name:SUPIK, DENISE
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:SUPIK
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:DENISE
Other - Middle Name:
Other - Last Name:SUPIK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:600 WYNDHURST AVE STE 308
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21210-2415
Mailing Address - Country:US
Mailing Address - Phone:443-310-8214
Mailing Address - Fax:
Practice Address - Street 1:600 WYNDHURST AVE STE 308
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21210-2415
Practice Address - Country:US
Practice Address - Phone:443-310-8214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-13
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC1280101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD45-5476114OtherTAX ID