Provider Demographics
NPI:1790815074
Name:MONGAN, ELLEN MARIE (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:MARIE
Last Name:MONGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 5391
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-0391
Mailing Address - Country:US
Mailing Address - Phone:410-929-4617
Mailing Address - Fax:855-234-9097
Practice Address - Street 1:6701 N CHARLES ST STE 4104
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21204-6808
Practice Address - Country:US
Practice Address - Phone:410-938-5382
Practice Address - Fax:410-938-4806
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00658402084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry