Healthcare Provider Details

I. General information

NPI: 1073271144
Provider Name (Legal Business Name): MARYAM BOLOUKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2021
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5457 TWIN KNOLLS RD STE 300-N18
COLUMBIA MD
21045-3259
US

IV. Provider business mailing address

7903 ORION CIR UNIT 360
LAUREL MD
20724-3112
US

V. Phone/Fax

Practice location:
  • Phone: 301-265-6442
  • Fax:
Mailing address:
  • Phone: 301-265-6442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBA2100
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: