Provider Demographics
NPI:1255629341
Name:DOREN, MARISUE DIANE (PT)
Entity type:Individual
Prefix:MRS
First Name:MARISUE
Middle Name:DIANE
Last Name:DOREN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6901 N CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-3780
Mailing Address - Country:US
Mailing Address - Phone:443-809-3660
Mailing Address - Fax:
Practice Address - Street 1:105 W CHESAPEAKE AVE
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-4725
Practice Address - Country:US
Practice Address - Phone:443-809-3660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013709-1225100000X
MD28655225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist