Provider Demographics
NPI:1720203219
Name:STEVENSON, MARLENE GAZELLA (CAC-AD, MHS)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:GAZELLA
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:CAC-AD, MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5811 WINNER AVENUE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215
Mailing Address - Country:US
Mailing Address - Phone:410-400-1857
Mailing Address - Fax:
Practice Address - Street 1:1501 W. SARATOGA STREET
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21223
Practice Address - Country:US
Practice Address - Phone:410-383-3129
Practice Address - Fax:410-383-3131
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDACO713101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)