Healthcare Provider Details

I. General information

NPI: 1730863622
Provider Name (Legal Business Name): MICHAEL CARDACI, LCPC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 07/14/2023
Certification Date: 07/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2616 CHAPEL LAKE DR STE B
GAMBRILLS MD
21054-1637
US

IV. Provider business mailing address

242 NATHAN WAY
MILLERSVILLE MD
21108-1033
US

V. Phone/Fax

Practice location:
  • Phone: 410-714-1720
  • Fax: 410-775-9770
Mailing address:
  • Phone: 410-714-1720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL D CARDACI
Title or Position: RESIDENT AGENT/OWNER
Credential: LCPC
Phone: 410-714-1720