MEDICARE: DE'TRECE ATALIE LAVENDER NCC. LCPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	LC14772	MD

General Provider Information

NPI Number	:	1073274387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DE'TRECE ATALIE LAVENDER NCC. LCPC

Provider Business Mailing Address
First Line	:	4904 YORK RD UNIT 4506
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21212-7501
Country	:	US
Telephone Number	:	240-565-0569
Fax Number	:	240-427-9390

Provider Business Practice Location Address
First Line	:	4904 YORK RD UNIT 4506
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21212-7501
Country	:	US
Telephone Number	:	240-565-0569
Fax Number	:	240-427-9390

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/07/2022
Last Update Date	:	08/30/2024

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