Provider Demographics
NPI:1073115358
Name:ETUKUDO, MARYANN
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:
Last Name:ETUKUDO
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 1:14625 BALTIMORE AVE # 817
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-4902
Mailing Address - Country:US
Mailing Address - Phone:240-806-8401
Mailing Address - Fax:
Practice Address - Street 1:14625 BALTIMORE AVE # 817
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-4902
Practice Address - Country:US
Practice Address - Phone:240-806-8401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty