1053777995 NPI number — TANDRA NICOLE BROWN LEE LICSW, LCSW-C

Table of content: TANDRA NICOLE BROWN LEE LICSW, LCSW-C (NPI 1053777995)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053777995 NPI number — TANDRA NICOLE BROWN LEE LICSW, LCSW-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEE
Provider First Name:
TANDRA
Provider Middle Name:
NICOLE BROWN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICSW, LCSW-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BROWN
Provider Other First Name:
TANDRA
Provider Other Middle Name:
NICOLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LGSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1053777995
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/31/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3519 REGENCY PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DISTRICT HEIGHTS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20747-3819
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
240-274-4702
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3519 REGENCY PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DISTRICT HEIGHTS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20747-3819
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-274-4702
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/07/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  13915 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: LC50081239 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 13915 . This is a "LCSW-C" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: LG50079107 . This is a "DISTRICT OF COLUMBIA BOARD OF SOCIAL WORK" identifier . This identifiers is of the category "OTHER".
  • Identifier: LC50081239 . This is a "LICSW" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".




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