Basic Information
| Provider Information | |||||||||
| NPI: | 1063426104 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NORTH | ||||||||
| FirstName: | MARIELLEN | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NORTH | ||||||||
| OtherFirstName: | MARIELLEN | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | PROF. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PHD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4351 TEN OAKS RD | ||||||||
| Address2: | SUITE309 | ||||||||
| City: | DAYTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210361132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108252281 | ||||||||
| FaxNumber: | 4108250757 | ||||||||
| Practice Location | |||||||||
| Address1: | 1407 YORK RD | ||||||||
| Address2: | SUITE309 | ||||||||
| City: | LUTHERVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210936097 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108252281 | ||||||||
| FaxNumber: | 4108250757 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 02149 | MD | X | Behavioral Health & Social Service Providers | Psychologist | 103TA0700X | 02149 | MD | X | Behavioral Health & Social Service Providers | Psychologist | Adult Development & Aging | 103TC0700X | 02149 | MD | X | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | 02149 | MD | X | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
No ID Information.