Basic Information
| Provider Information | |||||||||
| NPI: | 1063422012 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAZNICK | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RAZNICK | ||||||||
| OtherFirstName: | DAVID | ||||||||
| OtherMiddleName: | JOEL | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1380 PROGRESS WAY | ||||||||
| Address2: | 101 | ||||||||
| City: | ELDERSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105495181 | ||||||||
| FaxNumber: | 4105495182 | ||||||||
| Practice Location | |||||||||
| Address1: | 1380 PROGRESS WAY | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | ELDERSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105495181 | ||||||||
| FaxNumber: | 4105495182 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 09/23/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 1467 | MD | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 649141300 | 05 | MD | MEDICAID |