Healthcare Provider Details

I. General information

NPI: 1760291702
Provider Name (Legal Business Name): MT. AIRY PSYCHOLOGICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2025
Last Update Date: 01/03/2025
Certification Date: 01/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 E RIDGEVILLE BLVD
MOUNT AIRY MD
21771-5249
US

IV. Provider business mailing address

603 E RIDGEVILLE BLVD
MOUNT AIRY MD
21771-5249
US

V. Phone/Fax

Practice location:
  • Phone: 301-200-3853
  • Fax:
Mailing address:
  • Phone: 667-354-1201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: LORA SPEAKE
Title or Position: CO-OWNER
Credential:
Phone: 667-354-1201