Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | 1741 | MD |
N | 103T00000X | Psychologist | 1741 | MD |
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | 1741 | MD |
N | 103G00000X | Clinical Psychologist | 1741 | MD |
N | 103TC0700X | Clinical Psychologist | 1741 | MD |
N | 103TF0000X | Family Psychologist | 1741 | MD |
N | 103TH0100X | Health Service | 1741 | MD |
NPI | 1205977204 |
---|---|
Provider Name | Dr. Martin Bruce Koretzky |
First Address | Baltimore, MD 21209-2537 |
Second Address | Lutherville, MD 21093-4517 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/02/2007 |
Last Update Date | 08/07/2007 |