MEDICARE: DANIELLE MARIE AUDLEY LGPC

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	101YM0800X	Mental Health Counselor	LGP11107	MD
2	101Y00000X	Counselor	LGP11107	MD

General Provider Information

NPI Number	:	1659961688
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIELLE MARIE AUDLEY LGPC

Provider Business Mailing Address
First Line	:	10244 HICKORY RIDGE RD APT 402
Second Line	:
City	:	COLUMBIA
State	:	MD
Zip	:	21044-4674
Country	:	US
Telephone Number	:	631-786-9370
Fax Number	:

Provider Business Practice Location Address
First Line	:	6310 STEVENS FOREST RD
Second Line	:
City	:	COLUMBIA
State	:	MD
Zip	:	21046-1036
Country	:	US
Telephone Number	:	410-740-3240
Fax Number	:

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

Provider Enumeration Date	:	01/23/2021
Last Update Date	:	01/23/2021

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