Healthcare Provider Details

I. General information

NPI: 1720696214
Provider Name (Legal Business Name): AMY VICTORIA MARANTO MS, LGPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2020
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6440 DOBBIN RD STE D
COLUMBIA MD
21045-4770
US

IV. Provider business mailing address

1826 YAKONA RD
PARKVILLE MD
21234-3615
US

V. Phone/Fax

Practice location:
  • Phone: 410-730-2385
  • Fax:
Mailing address:
  • Phone: 443-695-6184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGP10633
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: