Healthcare Provider Details

I. General information

NPI: 1174036636
Provider Name (Legal Business Name): SEAN A. HAYES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2017
Last Update Date: 11/02/2021
Certification Date: 11/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19727 EXECUTIVE PARK CIR
GERMANTOWN MD
20874-2642
US

IV. Provider business mailing address

PO BOX 882
CLARKSBURG MD
20871-0882
US

V. Phone/Fax

Practice location:
  • Phone: 301-972-1373
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: SEAN A. HAYES
Title or Position: OWNER
Credential: B.S.
Phone: 301-972-1373