Provider Demographics
NPI:1063426104
Name:NORTH, MARIELLEN E (PHD)
Entity type:Individual
Prefix:DR
First Name:MARIELLEN
Middle Name:E
Last Name:NORTH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:PROF
Other - First Name:MARIELLEN
Other - Middle Name:E
Other - Last Name:NORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:4351 TEN OAKS RD
Mailing Address - Street 2:SUITE309
Mailing Address - City:DAYTON
Mailing Address - State:MD
Mailing Address - Zip Code:21036-1132
Mailing Address - Country:US
Mailing Address - Phone:410-825-2281
Mailing Address - Fax:410-825-0757
Practice Address - Street 1:1407 YORK RD
Practice Address - Street 2:SUITE309
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-6097
Practice Address - Country:US
Practice Address - Phone:410-825-2281
Practice Address - Fax:410-825-0757
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02149103T00000X, 103TA0700X, 103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC011791J69Medicare ID - Type Unspecified
MDR95492Medicare UPIN
MD361LG111Medicare ID - Type Unspecified