Healthcare Provider Details

I. General information

NPI: 1194980177
Provider Name (Legal Business Name): CHRISTA MARVENKO-ATHAS LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2008
Last Update Date: 07/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W CHESAPEAKE AVE SUITE L12
TOWSON MD
21204-4421
US

IV. Provider business mailing address

305 W CHESAPEAKE AVE SUITE L12
TOWSON MD
21204-4421
US

V. Phone/Fax

Practice location:
  • Phone: 410-367-1029
  • Fax:
Mailing address:
  • Phone: 410-367-1029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11258
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: