Healthcare Provider Details

I. General information

NPI: 1255850129
Provider Name (Legal Business Name): PASSAGEWAYS THERAPY AND COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2017
Last Update Date: 09/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 N JEFFERSON ST STE 403
FREDERICK MD
21701-4823
US

IV. Provider business mailing address

10 N. JEFFERSON STREET SUITE 403
FREDERICK MD
21782-1702
US

V. Phone/Fax

Practice location:
  • Phone: 301-514-4745
  • Fax: 301-668-1854
Mailing address:
  • Phone: 301-514-4745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17036
License Number StateMD

VIII. Authorized Official

Name: TAMARA LYNN KOEPP
Title or Position: SOLE MEMBER
Credential: LCSW-C
Phone: 301-514-4745