Provider Demographics
NPI:1790180701
Name:IZRAELSON, MARIANA (LCADC)
Entity Type:Individual
Prefix:
First Name:MARIANA
Middle Name:
Last Name:IZRAELSON
Suffix:
Gender:F
Credentials:LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 REDARE CT
Mailing Address - Street 2:
Mailing Address - City:PARKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21234-1867
Mailing Address - Country:US
Mailing Address - Phone:420-412-0496
Mailing Address - Fax:
Practice Address - Street 1:201 E BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-1535
Practice Address - Country:US
Practice Address - Phone:410-649-0529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-03
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1737101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)