Provider Demographics
NPI:1427228584
Name:MARY BLOTZER LCSW C PA
Entity Type:Organization
Organization Name:MARY BLOTZER LCSW C PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLOTZER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW C
Authorized Official - Phone:240-374-3263
Mailing Address - Street 1:7310 QUANTUM LEAP LN
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-4301
Mailing Address - Country:US
Mailing Address - Phone:240-374-3263
Mailing Address - Fax:
Practice Address - Street 1:7310 QUANTUM LEAP LN
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720-4301
Practice Address - Country:US
Practice Address - Phone:240-374-3263
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD055571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD014653600Medicaid
MD014653600Medicaid
MD641436Medicare PIN