Healthcare Provider Details

I. General information

NPI: 1841043411
Provider Name (Legal Business Name): MR. LES CUPIDON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2024
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16220 FREDERICK RD STE 310
GAITHERSBURG MD
20877-4020
US

IV. Provider business mailing address

1003 W 7TH ST STE 500
FREDERICK MD
21701-8512
US

V. Phone/Fax

Practice location:
  • Phone: 301-345-1022
  • Fax:
Mailing address:
  • Phone: 301-345-1022
  • Fax: 301-560-5558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLGP11857
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: