Healthcare Provider Details

I. General information

NPI: 1629548433
Provider Name (Legal Business Name): STEPHANIE WALKER LGPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2018
Last Update Date: 12/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 CHINQUAPIN ROUND RD
ANNAPOLIS MD
21401-4006
US

IV. Provider business mailing address

3504 DERBY SHIRE CIR
WINDSOR MILL MD
21244-3624
US

V. Phone/Fax

Practice location:
  • Phone: 410-990-1811
  • Fax: 443-949-7379
Mailing address:
  • Phone: 443-418-7463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGP8674
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: