Healthcare Provider Details

I. General information

NPI: 1245645514
Provider Name (Legal Business Name): MARIE WOODS CPRP, CIT-AD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2014
Last Update Date: 06/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 S. BROADWAY ST.
BALTIMORE MD
21231
US

IV. Provider business mailing address

14 S BROADWAY
BALTIMORE MD
21231-1712
US

V. Phone/Fax

Practice location:
  • Phone: 443-934-5119
  • Fax:
Mailing address:
  • Phone: 443-934-5119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number4882460
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: