Provider Demographics
NPI:1447307533
Name:CARBAUGH, MARYELLEN CAGGIANO (LPCMH)
Entity type:Individual
Prefix:MRS
First Name:MARYELLEN
Middle Name:CAGGIANO
Last Name:CARBAUGH
Suffix:
Gender:F
Credentials:LPCMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1155
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19903-1155
Mailing Address - Country:US
Mailing Address - Phone:302-734-7750
Mailing Address - Fax:302-736-5265
Practice Address - Street 1:1132 S LITTLE CREEK RD
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-4727
Practice Address - Country:US
Practice Address - Phone:302-734-7750
Practice Address - Fax:302-736-5265
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEPC-0000238101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000022278Medicaid