Healthcare Provider Details

I. General information

NPI: 1922395847
Provider Name (Legal Business Name): CITY PARK PSYCHOLOGICAL SERVICES & ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 08/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 W PATRICK ST
FREDERICK MD
21701-5515
US

IV. Provider business mailing address

209 W PATRICK ST
FREDERICK MD
21701-5515
US

V. Phone/Fax

Practice location:
  • Phone: 301-401-2813
  • Fax:
Mailing address:
  • Phone: 301-401-2813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2139
License Number StateMD

VIII. Authorized Official

Name: DR. LOU A LICHTI
Title or Position: OWNER/PSYCHOLOGIST
Credential: PH.D.
Phone: 301-401-2813