Healthcare Provider Details

I. General information

NPI: 1922410109
Provider Name (Legal Business Name): SEASIDE COUNSELING & WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2014
Last Update Date: 11/18/2022
Certification Date: 11/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 FRANKLIN AVE SUITE 306
BERLIN MD
21811
US

IV. Provider business mailing address

314 FRANKLIN AVE SUITE 306
BERLIN MD
21811
US

V. Phone/Fax

Practice location:
  • Phone: 410-973-2525
  • Fax: 410-973-2527
Mailing address:
  • Phone: 410-973-2525
  • Fax: 410-973-2527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: AMY GINNAVAN
Title or Position: OWNER
Credential: LCSW-C
Phone: 410-973-2525