Provider Demographics
NPI:1073674586
Name:TAYLOR-ENNIS, MARY L (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:L
Last Name:TAYLOR-ENNIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6231 FERNWAY
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-2506
Mailing Address - Country:US
Mailing Address - Phone:410-323-4582
Mailing Address - Fax:
Practice Address - Street 1:5601 LOCH RAVEN BLVD STE 301-A
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21239-2905
Practice Address - Country:US
Practice Address - Phone:443-444-5798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD84-1713024103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD251502400Medicaid
MD338RMedicare PIN