Healthcare Provider Details

I. General information

NPI: 1336731116
Provider Name (Legal Business Name): EMOTIONAL ABUSE SUPPORT TEAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2021
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1808 61ST AVE
CHEVERLY MD
20785-3803
US

IV. Provider business mailing address

1808 61ST AVE
CHEVERLY MD
20785-3803
US

V. Phone/Fax

Practice location:
  • Phone: 240-319-0182
  • Fax:
Mailing address:
  • Phone: 240-319-0182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DEMAREST CRAWL
Title or Position: EXECUTIVE
Credential: LCSW-C
Phone: 240-319-0182