Healthcare Provider Details

I. General information

NPI: 1205874260
Provider Name (Legal Business Name): MELVIN E PRIDE LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6916 DOGWOOD RD
BALTIMORE MD
21244-2604
US

IV. Provider business mailing address

10396 STANSFIELD RD
LAUREL MD
20723-1277
US

V. Phone/Fax

Practice location:
  • Phone: 410-882-1988
  • Fax:
Mailing address:
  • Phone: 410-880-0865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC1127
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: