Healthcare Provider Details

I. General information

NPI: 1528629540
Provider Name (Legal Business Name): MARYLAND VIRTUAL COUNSELING LLC,
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2019
Last Update Date: 06/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 KUETHE RD
GLEN BURNIE MD
21060-7322
US

IV. Provider business mailing address

642 THOMAS WAY
SEVERNA PARK MD
21146-2832
US

V. Phone/Fax

Practice location:
  • Phone: 443-203-8098
  • Fax:
Mailing address:
  • Phone: 443-250-6653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: ALLISON PASTINE
Title or Position: OWNER
Credential: LPCPC
Phone: 443-250-6653