Provider Demographics
NPI:1770505331
Name:DISNEY, ELIZABETH RENEE (PHD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:RENEE
Last Name:DISNEY
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 1:6325 WOODSIDE CT STE 350
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21046-1042
Mailing Address - Country:US
Mailing Address - Phone:410-910-9660
Mailing Address - Fax:
Practice Address - Street 1:6325 WOODSIDE CT STE 350
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-1042
Practice Address - Country:US
Practice Address - Phone:410-910-9660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04064101YA0400X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD521316900Medicaid