Healthcare Provider Details

I. General information

NPI: 1104306414
Provider Name (Legal Business Name): CURTIS TOMMY CLAIR JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2018
Last Update Date: 07/24/2023
Certification Date: 07/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9701 APOLLO DR STE 100
LARGO MD
20774-4785
US

IV. Provider business mailing address

214 DAUNTLY ST
UPPER MARLBORO MD
20774-1810
US

V. Phone/Fax

Practice location:
  • Phone: 301-343-4713
  • Fax:
Mailing address:
  • Phone: 301-343-4713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLGP8618
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLGP8618
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGP8618
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLGP8618
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC13983
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: