Healthcare Provider Details

I. General information

NPI: 1174283030
Provider Name (Legal Business Name): AYSIA CHANEL STOVALL LGPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2021
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 MARTIN LUTHER KING JR AVE SE
WASHINGTON DC
20032-1542
US

IV. Provider business mailing address

3400 MARTIN LUTHER KING JR AVE SE
WASHINGTON DC
20032-1542
US

V. Phone/Fax

Practice location:
  • Phone: 202-724-7666
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: