Healthcare Provider Details

I. General information

NPI: 1316775869
Provider Name (Legal Business Name): OMNIA SALEM LGPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2024
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13228 EXECUTIVE PARK TER
GERMANTOWN MD
20874-2640
US

IV. Provider business mailing address

13228 EXECUTIVE PARK TER
GERMANTOWN MD
20874-2640
US

V. Phone/Fax

Practice location:
  • Phone: 240-489-1108
  • Fax: 240-474-0068
Mailing address:
  • Phone: 240-489-1108
  • Fax: 240-474-0068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGP15347
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: