Provider Demographics
NPI:1700408291
Name:MATHIAS, MARILYN ROBERTA (LCSW-C)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:ROBERTA
Last Name:MATHIAS
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14812 WOODFIELD LN
Mailing Address - Street 2:
Mailing Address - City:GLENELG
Mailing Address - State:MD
Mailing Address - Zip Code:21737-9400
Mailing Address - Country:US
Mailing Address - Phone:301-802-5783
Mailing Address - Fax:
Practice Address - Street 1:14812 WOODFIELD LN
Practice Address - Street 2:
Practice Address - City:GLENELG
Practice Address - State:MD
Practice Address - Zip Code:21737-9400
Practice Address - Country:US
Practice Address - Phone:301-802-5783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-07
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD048471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD04847OtherBOARD OF SOCIAL WORK EXAMINERS