Healthcare Provider Details

I. General information

NPI: 1770122145
Provider Name (Legal Business Name): KENTLANDS PSYCHOTHERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2020
Last Update Date: 01/02/2020
Certification Date: 01/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 INSPIRATION LN FL 2
GAITHERSBURG MD
20878-5817
US

IV. Provider business mailing address

301 INSPIRATION LN FL 2
GAITHERSBURG MD
20878-5817
US

V. Phone/Fax

Practice location:
  • Phone: 240-252-3349
  • Fax: 240-477-5265
Mailing address:
  • Phone: 240-252-3349
  • Fax: 240-477-5265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ELIZABETH C. CARR
Title or Position: OWNER
Credential: PSYD
Phone: 240-252-3349