Healthcare Provider Details

I. General information

NPI: 1366563322
Provider Name (Legal Business Name): MARK PALMISANO, PHD P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 09/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 TOLL HOUSE AVE UNIT A-3
FREDERICK MD
21701-4564
US

IV. Provider business mailing address

801 TOLL HOUSE AVE UNIT A-3
FREDERICK MD
21701-4564
US

V. Phone/Fax

Practice location:
  • Phone: 301-788-2989
  • Fax: 301-663-1412
Mailing address:
  • Phone: 301-788-2989
  • Fax: 301-663-1412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number03154
License Number StateMD

VIII. Authorized Official

Name: DR. MARK PALMISANO
Title or Position: PROVIDER
Credential: PHD
Phone: 301-788-2989