1518443274 NPI number — LAVENDER HILLS PSYCHOTHERAPY LLC

Table of content: (NPI 1518443274)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518443274 NPI number — LAVENDER HILLS PSYCHOTHERAPY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAVENDER HILLS PSYCHOTHERAPY 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:
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Provider Other Name Prefix Text:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1518443274
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/24/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11140 ROCKVILLE PIKE STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
N BETHESDA
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20852-3104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
240-230-6668
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11140 ROCKVILLE PIKE STE 400
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH BETHESDA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20852-3104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-230-6668
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/16/2018

Additional Information

Authorized Official

Authorized Official Last Name:
HENRIQUEZ
Authorized Official First Name:
PAULA
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICAL PSYCHOLOGIST
Authorized Official Telephone Number:
240-230-6668

Provider Taxonomy Codes

  • Taxonomy code: 103TC2200X , with the licence number:  05723 , 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)

  • Identifier: 1598071433 . This is a "CLINICAL PSYCHOLOGIST" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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