=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356330872
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARILYN ANSEVIN AUSTIN PH.D.,LCSW-C, BCD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19345 OLNEY MILL RD
-----------------------------------------------------
City | OLNEY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20832-1101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-570-9143
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19345 OLNEY MILL RD
-----------------------------------------------------
City | OLNEY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20832-1101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-570-9143
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 778
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------