Healthcare Provider Details

I. General information

NPI: 1568030427
Provider Name (Legal Business Name): MARYUM FIELDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2021
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 VOORHEES TOWN CTR
VOORHEES NJ
08043-1910
US

IV. Provider business mailing address

1551 E HEWSON ST
PHILADELPHIA PA
19125-2807
US

V. Phone/Fax

Practice location:
  • Phone: 856-346-0005
  • Fax:
Mailing address:
  • Phone: 484-919-9619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBH005238
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-145512
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: