Healthcare Provider Details

I. General information

NPI: 1356644116
Provider Name (Legal Business Name): BRENDA DORSCH IBUTU LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2010
Last Update Date: 12/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3902 ANNAPOLIS RD
LANSDOWNE MD
21227-2249
US

IV. Provider business mailing address

3902 ANNAPOLIS RD
LANSDOWNE MD
21227-2249
US

V. Phone/Fax

Practice location:
  • Phone: 410-789-2647
  • Fax: 410-789-8364
Mailing address:
  • Phone: 410-789-6247
  • Fax: 410-789-8364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLC3573
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLC3573
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC3573
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License NumberLC3573
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC3573
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: