Provider Demographics
NPI:1912124298
Name:MODDERMAN, MARYJOAN H (OTR)
Entity Type:Individual
Prefix:MS
First Name:MARYJOAN
Middle Name:H
Last Name:MODDERMAN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4107 HAMILTON ST
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20781-1804
Mailing Address - Country:US
Mailing Address - Phone:301-277-4911
Mailing Address - Fax:
Practice Address - Street 1:14201 SCHOOL LN
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-2866
Practice Address - Country:US
Practice Address - Phone:301-567-8494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01236174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist