Healthcare Provider Details

I. General information

NPI: 1699604124
Provider Name (Legal Business Name): MARIAM DOHERTY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5249 KENILWORTH AVE APT 103
HYATTSVILLE MD
20781-2863
US

IV. Provider business mailing address

5249 KENILWORTH AVE APT 103
HYATTSVILLE MD
20781-2863
US

V. Phone/Fax

Practice location:
  • Phone: 240-907-0050
  • Fax:
Mailing address:
  • Phone: 240-907-0050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: