Provider Demographics
NPI:1235694308
Name:WEISHAAR, MARTIN (LCPAT, LCPC)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:WEISHAAR
Suffix:
Gender:M
Credentials:LCPAT, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 50031
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-4031
Mailing Address - Country:US
Mailing Address - Phone:410-801-9600
Mailing Address - Fax:
Practice Address - Street 1:3000 CHESTNUT AVE STE 202A
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-2727
Practice Address - Country:US
Practice Address - Phone:410-801-9600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-04
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDATC251101YM0800X
MDLC10198101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDEJ14-0000OtherBLUE CROSS BLUE SHIELD
MD60054OtherAETNA
MD589044600OtherMEDICAID
MD833319030OtherCIGNA