Healthcare Provider Details

I. General information

NPI: 1891207163
Provider Name (Legal Business Name): JESSE TROVATO LGPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2017
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 WOODRIDGE MANOR RD
FALLSTON MD
21047-2656
US

IV. Provider business mailing address

1407 WOODRIDGE MANOR RD
FALLSTON MD
21047-2656
US

V. Phone/Fax

Practice location:
  • Phone: 410-625-1600
  • Fax:
Mailing address:
  • Phone: 410-625-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC9856
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC9856
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: