Provider Demographics
NPI:1124204854
Name:MARYLAND INSTITUTE FOR INDIVIDUAL & FAMILY THERAPY
Entity Type:Organization
Organization Name:MARYLAND INSTITUTE FOR INDIVIDUAL & FAMILY THERAPY
Other - Org Name:MARYLAND INSTITUTE
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:P
Authorized Official - Last Name:FAGO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:301-277-3250
Mailing Address - Street 1:7307 BALTIMORE AVE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20740-3231
Mailing Address - Country:US
Mailing Address - Phone:301-277-3250
Mailing Address - Fax:301-927-8052
Practice Address - Street 1:7307 BALTIMORE AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740-3231
Practice Address - Country:US
Practice Address - Phone:301-277-3250
Practice Address - Fax:301-927-8052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01730103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty