Healthcare Provider Details

I. General information

NPI: 1285780445
Provider Name (Legal Business Name): MARIANNE JEANNE MORAN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WAAF CLINIC UNIT 29623
APO AE
09096
DE

IV. Provider business mailing address

CMR 467 BOX 218
APO AE
09096
DE

V. Phone/Fax

Practice location:
  • Phone: 613-455-6104
  • Fax:
Mailing address:
  • Phone: 611-716-4258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number03320
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: