Healthcare Provider Details

I. General information

NPI: 1609462258
Provider Name (Legal Business Name): SAVANNAH CHAMBERLAIN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2020
Last Update Date: 12/17/2020
Certification Date: 12/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 RADIO STATION RD
LA PLATA MD
20646-3314
US

IV. Provider business mailing address

4613 JOHN ST
SUITLAND MD
20746-3772
US

V. Phone/Fax

Practice location:
  • Phone: 301-609-9887
  • 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 StateNULL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number25740
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: