Provider Demographics
NPI:1609109131
Name:THE METAMORPHORSIS INSTITUTE, LLC
Entity Type:Organization
Organization Name:THE METAMORPHORSIS INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:TAYLOR-ENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:443-444-5798
Mailing Address - Street 1:7131 LIBERTY RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21207-4575
Mailing Address - Country:US
Mailing Address - Phone:443-436-3003
Mailing Address - Fax:443-436-3002
Practice Address - Street 1:7131 LIBERTY RD
Practice Address - Street 2:SUITE 202
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21207-4575
Practice Address - Country:US
Practice Address - Phone:443-436-3003
Practice Address - Fax:443-436-3002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-16
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03567103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD251502400Medicaid
MD251502400Medicaid