MEDICARE: DR. MARYANNE BONGIOVANI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC2200X	Clinical Child & Adolescent Psychologist	02316	MD

General Provider Information

NPI Number	:	1164570354
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARYANNE BONGIOVANI

Provider Business Mailing Address
First Line	:	10527 DORCHESTER WAY
Second Line	:
City	:	WOODSTOCK
State	:	MD
Zip	:	21163-1377
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9050 CHEVROLET DR
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-4018
Country	:	US
Telephone Number	:	410-750-9493
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/06/2007
Last Update Date	:	07/08/2007

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