Healthcare Provider Details

I. General information

NPI: 1710892880
Provider Name (Legal Business Name): ELLEN RUTH HEAVNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2644 RIVA RD
ANNAPOLIS MD
21401-7427
US

IV. Provider business mailing address

21 DONZI CT
SEVERNA PARK MD
21146-4825
US

V. Phone/Fax

Practice location:
  • Phone: 410-222-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberCER-196713-K8H3C9
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: