Healthcare Provider Details

I. General information

NPI: 1598227043
Provider Name (Legal Business Name): LAVINA MIRANDA THOMPSON BOWLING LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 MERCANTILE LN STE 198
LARGO MD
20774-5339
US

IV. Provider business mailing address

6314 GLENN DALE RD
GLENN DALE MD
20769-9207
US

V. Phone/Fax

Practice location:
  • Phone: 301-386-2991
  • Fax: 301-386-1944
Mailing address:
  • Phone: 732-801-9006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC7467
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: