Provider Demographics
NPI:1073271144
Name:BOLOUKI, MARYAM
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:BOLOUKI
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7903 ORION CIR UNIT 340
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20724-3111
Mailing Address - Country:US
Mailing Address - Phone:301-265-6442
Mailing Address - Fax:
Practice Address - Street 1:7903 ORION CIR UNIT 340
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20724-3111
Practice Address - Country:US
Practice Address - Phone:301-265-6442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-06
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLBA2100103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst