Provider Demographics
NPI:1619955721
Name:VIETEN, MARY NEAL (PHD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:NEAL
Last Name:VIETEN
Suffix:
Gender:F
Credentials:PHD
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 222
Mailing Address - Street 2:
Mailing Address - City:PATUXENT RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:20670-0222
Mailing Address - Country:US
Mailing Address - Phone:301-769-8081
Mailing Address - Fax:
Practice Address - Street 1:20797 RED ROSE CT
Practice Address - Street 2:
Practice Address - City:LEXINGTON PARK
Practice Address - State:MD
Practice Address - Zip Code:20653-2447
Practice Address - Country:US
Practice Address - Phone:301-769-8081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04514103TC0700X
IN20041604A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD415557800Medicaid
MD415557800Medicaid