Healthcare Provider Details

I. General information

NPI: 1538003629
Provider Name (Legal Business Name): MARISSA LIGHTKEP MS, LGPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2026
Last Update Date: 04/17/2026
Certification Date: 04/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3459 SAINT JOHNS LN STE 7
ELLICOTT CITY MD
21042-4026
US

IV. Provider business mailing address

3459 SAINT JOHNS LN STE 7
ELLICOTT CITY MD
21042-4026
US

V. Phone/Fax

Practice location:
  • Phone: 443-297-9292
  • Fax:
Mailing address:
  • Phone: 215-872-4575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLGP17713
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: