Healthcare Provider Details

I. General information

NPI: 1952070633
Provider Name (Legal Business Name): LINDSEY PROVELENGIOS LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2021
Last Update Date: 10/03/2022
Certification Date: 09/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 GATEWAY DR STE 1A
BEL AIR MD
21014-4266
US

IV. Provider business mailing address

1315 ROMAN RIDGE WAY
BEL AIR MD
21014-1894
US

V. Phone/Fax

Practice location:
  • Phone: 443-266-2294
  • Fax:
Mailing address:
  • Phone: 443-547-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC12399
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLGP9036
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: