Provider Demographics
NPI:1053538926
Name:MASTRACCO, MARIE E (LCPC)
Entity type:Individual
Prefix:MS
First Name:MARIE
Middle Name:E
Last Name:MASTRACCO
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1927A YORK RD REAR
Mailing Address - Street 2:
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-4225
Mailing Address - Country:US
Mailing Address - Phone:443-417-4243
Mailing Address - Fax:315-245-0352
Practice Address - Street 1:1927A YORK RD
Practice Address - Street 2:REAR BUILDING
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-4225
Practice Address - Country:US
Practice Address - Phone:443-417-4243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC2273101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD922801200Medicaid