Basic Information
| Provider Information | |||||||||
| NPI: | 1013251826 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTERDYNAMICS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4601 FORBES BLVD | ||||||||
| Address2: | |||||||||
| City: | LANHAM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207064807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013064590 | ||||||||
| FaxNumber: | 3013064591 | ||||||||
| Practice Location | |||||||||
| Address1: | 4601 FORBES BLVD | ||||||||
| Address2: | |||||||||
| City: | LANHAM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207064807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013064590 | ||||||||
| FaxNumber: | 3013064591 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2012 | ||||||||
| LastUpdateDate: | 11/16/2012 | ||||||||
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| AuthorizedOfficialLastName: | BALLARD | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | MOSES | ||||||||
| AuthorizedOfficialTitleorPosition: | PSYCHOLOGY | ||||||||
| AuthorizedOfficialTelephone: | 3013064590 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | PSY354 | DC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 01160 | MD | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 103T00000X | 01160 | MD | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | PSY354 | DC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 103TA0700X | PSY354 | DC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Adult Development & Aging | 103TB0200X | 01160 | MD | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 103TC0700X | 01160 | MD | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | PSY354 | DC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC1900X | 01160 | MD | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Counseling | 103TC2200X | 01160 | MD | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TC2200X | PSY354 | DC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TF0000X | 01160 | MD | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Family | 106H00000X | 01160 | MD | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | PSY354 | DC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YM0800X | 01160 | MD | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.