Provider Demographics
NPI:1790722189
Name:MOREAULT, DENISE MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:DENISE
Middle Name:MARIE
Last Name:MOREAULT
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 1:2712 WHITNEY AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-4159
Mailing Address - Country:US
Mailing Address - Phone:410-435-7700
Mailing Address - Fax:410-435-5598
Practice Address - Street 1:1501 SULGRAVE AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-3654
Practice Address - Country:US
Practice Address - Phone:410-435-7700
Practice Address - Fax:410-435-5598
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01399103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG621Medicare ID - Type Unspecified
MDG621Medicare UPIN