Healthcare Provider Details

I. General information

NPI: 1639273824
Provider Name (Legal Business Name): MARY ELIZABETH CULLEN DZAMAN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BETH CULLEN DZAMAN PH.D.

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 01/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 S HANOVER ST
BALTIMORE MD
21201-2438
US

IV. Provider business mailing address

516 S HANOVER ST
BALTIMORE MD
21201-2438
US

V. Phone/Fax

Practice location:
  • Phone: 410-528-0211
  • Fax: 413-235-2570
Mailing address:
  • Phone: 410-528-0211
  • Fax: 413-235-2570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1863
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1355
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: