Healthcare Provider Details

I. General information

NPI: 1275167678
Provider Name (Legal Business Name): SAMANTHA QUACKENBUSH LGPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2020
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5550 FRIENDSHIP BLVD STE 590
CHEVY CHASE MD
20815-7310
US

IV. Provider business mailing address

184 UNSER BLVD NE
RIO RANCHO NM
87124-4045
US

V. Phone/Fax

Practice location:
  • Phone: 888-470-0954
  • Fax: 240-235-8720
Mailing address:
  • Phone: 505-896-0928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLGP18444
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: