Healthcare Provider Details

I. General information

NPI: 1457938904
Provider Name (Legal Business Name): CARLOS CORTES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 E DIAMOND AVE STE H
GAITHERSBURG MD
20877-5328
US

IV. Provider business mailing address

618 H ST SW APT 203
WASHINGTON DC
20024-2732
US

V. Phone/Fax

Practice location:
  • Phone: 301-840-3200
  • Fax:
Mailing address:
  • Phone: 504-813-9451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGP11178
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: