Provider Demographics
NPI:1649630716
Name:BLACKWOOD, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BLACKWOOD
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 1:5043 BRADLEY BLVD APT 3
Mailing Address - Street 2:
Mailing Address - City:CHEVY CHASE
Mailing Address - State:MD
Mailing Address - Zip Code:20815-6573
Mailing Address - Country:US
Mailing Address - Phone:301-922-1515
Mailing Address - Fax:
Practice Address - Street 1:6440 DOBBIN RD STE D
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-4770
Practice Address - Country:US
Practice Address - Phone:410-730-2385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-02
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCM492106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist