Healthcare Provider Details

I. General information

NPI: 1487591251
Provider Name (Legal Business Name): WATERSHED PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4405 E WEST HWY STE 411
BETHESDA MD
20814-4535
US

IV. Provider business mailing address

2325 N CALVERT ST
BALTIMORE MD
21218-5202
US

V. Phone/Fax

Practice location:
  • Phone: 717-478-8334
  • Fax:
Mailing address:
  • Phone: 717-478-8334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: CALLEEN TREVENEN
Title or Position: PARTNER
Credential: LCPC
Phone: 717-478-8334