Provider Demographics
NPI:1639273824
Name:DZAMAN, MARY ELIZABETH CULLEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY ELIZABETH
Middle Name:CULLEN
Last Name:DZAMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:BETH CULLEN
Other - Middle Name:
Other - Last Name:DZAMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:516 S HANOVER ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-2438
Mailing Address - Country:US
Mailing Address - Phone:410-528-0211
Mailing Address - Fax:413-235-2570
Practice Address - Street 1:516 S HANOVER ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-2438
Practice Address - Country:US
Practice Address - Phone:410-528-0211
Practice Address - Fax:413-235-2570
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2010-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1863103TC0700X
DC1355103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD651202000Medicaid
G153Medicare ID - Type Unspecified