Healthcare Provider Details

I. General information

NPI: 1033620364
Provider Name (Legal Business Name): ROGUE RIVER COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2017
Last Update Date: 07/16/2021
Certification Date: 07/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2007 TIDEWATER COLONY DR STE 1A
ANNAPOLIS MD
21401-2102
US

IV. Provider business mailing address

2007 TIDEWATER COLONY DR STE 1A
ANNAPOLIS MD
21401-2102
US

V. Phone/Fax

Practice location:
  • Phone: 410-294-9300
  • Fax: 410-294-9300
Mailing address:
  • Phone: 410-294-9300
  • Fax: 410-294-9300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC6340
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateMD

VIII. Authorized Official

Name: JASON HOVEY
Title or Position: OWNER
Credential: LCPC
Phone: 410-294-9300