Provider Demographics
NPI:1932141074
Name:BLACK, MAUREEN M (PHD)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:M
Last Name:BLACK
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:PO BOX 62063
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-2063
Mailing Address - Country:US
Mailing Address - Phone:410-706-5181
Mailing Address - Fax:410-706-5103
Practice Address - Street 1:120 PENN ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1082
Practice Address - Country:US
Practice Address - Phone:410-328-8336
Practice Address - Fax:410-328-4379
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1367103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD737510700Medicaid
S56887Medicare UPIN
MDC460Medicare PIN