Provider Demographics
NPI:1225534456
Name:DIZARD, ERICA JENEEN
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:JENEEN
Last Name:DIZARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7509 SHELOWOOD RD
Mailing Address - Street 2:
Mailing Address - City:PIKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-5724
Mailing Address - Country:US
Mailing Address - Phone:410-961-6090
Mailing Address - Fax:
Practice Address - Street 1:7519 STONES THROW CT
Practice Address - Street 2:
Practice Address - City:WINDSOR MILL
Practice Address - State:MD
Practice Address - Zip Code:21244-1232
Practice Address - Country:US
Practice Address - Phone:410-401-9799
Practice Address - Fax:443-548-2890
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-05
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD236261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical