1255850129 NPI number — PASSAGEWAYS THERAPY AND COUNSELING, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255850129 NPI number — PASSAGEWAYS THERAPY AND COUNSELING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PASSAGEWAYS THERAPY AND COUNSELING, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255850129
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 N. JEFFERSON STREET
Provider Second Line Business Mailing Address:
SUITE 403
Provider Business Mailing Address City Name:
FREDERICK
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21782-1702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-514-4745
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 N JEFFERSON ST STE 403
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREDERICK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21701-4823
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-514-4745
Provider Business Practice Location Address Fax Number:
301-668-1854
Provider Enumeration Date:
09/12/2017

Additional Information

Authorized Official

Authorized Official Last Name:
KOEPP
Authorized Official First Name:
TAMARA
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
SOLE MEMBER
Authorized Official Telephone Number:
301-514-4745

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  17036 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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