Healthcare Provider Details

I. General information

NPI: 1932141074
Provider Name (Legal Business Name): MAUREEN M BLACK PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 02/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 PENN ST
BALTIMORE MD
21201-1082
US

IV. Provider business mailing address

PO BOX 62063
BALTIMORE MD
21264-2063
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-8336
  • Fax: 410-328-4379
Mailing address:
  • Phone: 410-706-5181
  • Fax: 410-706-5103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number1367
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: