Healthcare Provider Details

I. General information

NPI: 1427175264
Provider Name (Legal Business Name): MARY JEAN PAVELKO LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 09/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 THOMAS JOHNSON DR. #200
FREDERICK MD
21702
US

IV. Provider business mailing address

170 THOMAS JOHNSON DR. #200
FREDERICK MD
21702
US

V. Phone/Fax

Practice location:
  • Phone: 301-695-8390
  • Fax: 301-694-7906
Mailing address:
  • Phone: 301-695-8390
  • Fax: 301-694-7906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number08398
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: