Provider Demographics
NPI:1558821892
Name:WALLER, MARJORIE CELESTE (ADT)
Entity Type:Individual
Prefix:MISS
First Name:MARJORIE
Middle Name:CELESTE
Last Name:WALLER
Suffix:
Gender:F
Credentials:ADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 MOUNTAIN ROAD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-0427
Mailing Address - Country:US
Mailing Address - Phone:443-548-3733
Mailing Address - Fax:410-360-1675
Practice Address - Street 1:2825 MOUNTAIN ROAD
Practice Address - Street 2:SUITE 204
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-0427
Practice Address - Country:US
Practice Address - Phone:443-548-3733
Practice Address - Fax:410-360-1675
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDADT1907101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)