Provider Demographics
NPI:1235481292
Name:PRENDERGAST, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:PRENDERGAST
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 1:3901 PUTTY HILL AVE
Mailing Address - Street 2:
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-3630
Mailing Address - Country:US
Mailing Address - Phone:443-725-4257
Mailing Address - Fax:
Practice Address - Street 1:4200 EDMONDSON AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-1612
Practice Address - Country:US
Practice Address - Phone:443-904-3174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC4306101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional