Healthcare Provider Details

I. General information

NPI: 1912784489
Provider Name (Legal Business Name): AMBER CONKLIN LGPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2023
Last Update Date: 09/11/2023
Certification Date: 09/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 MAITLAND ST
BEL AIR MD
21014-3939
US

IV. Provider business mailing address

1100 OLD MOUNTAIN RD N
JOPPA MD
21085-1612
US

V. Phone/Fax

Practice location:
  • Phone: 443-356-1452
  • Fax:
Mailing address:
  • Phone: 443-356-1452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLGP14306
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGP14306
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: