Provider Demographics
NPI:1538207568
Name:ATWATER, MARY (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:ATWATER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5604 RIDGEFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20816-1253
Mailing Address - Country:US
Mailing Address - Phone:301-807-8417
Mailing Address - Fax:
Practice Address - Street 1:4828 WEST LN STE B
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-6340
Practice Address - Country:US
Practice Address - Phone:301-807-8417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04053103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD491999Medicare ID - Type UnspecifiedMEDICARE