Provider Demographics
NPI:1164570354
Name:BONGIOVANI, MARYANNE
Entity Type:Individual
Prefix:DR
First Name:MARYANNE
Middle Name:
Last Name:BONGIOVANI
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 1:10527 DORCHESTER WAY
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:MD
Mailing Address - Zip Code:21163-1377
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9050 CHEVROLET DR
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-4018
Practice Address - Country:US
Practice Address - Phone:410-750-9493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02316103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent