Healthcare Provider Details

I. General information

NPI: 1346866522
Provider Name (Legal Business Name): MR. LARRY FRAZIER JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2020
Last Update Date: 06/23/2020
Certification Date: 06/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4615 MARY BETH BLVD
CLINTON MD
20735-9625
US

IV. Provider business mailing address

4615 MARY BETH BLVD
CLINTON MD
20735-9625
US

V. Phone/Fax

Practice location:
  • Phone: 202-246-1310
  • Fax:
Mailing address:
  • Phone: 202-246-1310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: