Healthcare Provider Details

I. General information

NPI: 1790217214
Provider Name (Legal Business Name): CABIN JOHN PSYCHIATRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 04/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 SEVEN LOCKS RD SUITE 206
CABIN JOHN MD
20818-1300
US

IV. Provider business mailing address

6500 SEVEN LOCKS RD SUITE 206
CABIN JOHN MD
20818-1300
US

V. Phone/Fax

Practice location:
  • Phone: 301-320-3701
  • Fax: 301-320-3774
Mailing address:
  • Phone: 301-320-3701
  • Fax: 301-320-3774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR160645
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberD19680
License Number StateMD

VIII. Authorized Official

Name: KRISTIN MARY SORENSEN-TANENBAUM
Title or Position: NURSE PRACTITIONER/OFFICE MANAGER
Credential: PMH-NP, FNP-C
Phone: 301-741-6101