Provider Demographics
NPI:1013371616
Name:MORAN CONLON, THERESE
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:
Last Name:MORAN CONLON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1381 JAY RD
Mailing Address - Street 2:
Mailing Address - City:ELDERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21784-6115
Mailing Address - Country:US
Mailing Address - Phone:410-552-9007
Mailing Address - Fax:410-552-9881
Practice Address - Street 1:1011 MAIN ST
Practice Address - Street 2:
Practice Address - City:HAMPSTEAD
Practice Address - State:MD
Practice Address - Zip Code:21074-2230
Practice Address - Country:US
Practice Address - Phone:410-552-9007
Practice Address - Fax:410-552-9881
Is Sole Proprietor?:No
Enumeration Date:2016-04-09
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC5216101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional