Healthcare Provider Details

I. General information

NPI: 1457972556
Provider Name (Legal Business Name): MADELINE R MARKS PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2020
Last Update Date: 08/04/2020
Certification Date: 08/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 W BALTIMORE ST
BALTIMORE MD
21201-1509
US

IV. Provider business mailing address

611 S CHARLES ST UNIT 323
BALTIMORE MD
21230-3881
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-6738
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberA0594
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: