Facts
- Status
- A
- Credential
- LSW
- Type
- Individual
- Enumeration date
- 2026-05-04
- Last updated
- 2026-05-04
Specialties
Licenses
- License CO
- LSW.0009925536
Location
- Practice location
- 2255 SHERIDAN BLVD UNIT C192
- City
- EDGEWATER CO
- Postal code
- 802141313
- Phone
- 443-944-3557
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.