Provider Demographics
NPI:1891431706
Name:STATMAN, ALIZA DIAMOND
Entity Type:Individual
Prefix:
First Name:ALIZA
Middle Name:DIAMOND
Last Name:STATMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2309 WHITLEY RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-3853
Mailing Address - Country:US
Mailing Address - Phone:410-952-2694
Mailing Address - Fax:
Practice Address - Street 1:2309 WHITLEY RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-3853
Practice Address - Country:US
Practice Address - Phone:410-952-2694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP12681101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health