Healthcare Provider Details

I. General information

NPI: 1134872757
Provider Name (Legal Business Name): DOUGLAS JAY SMITH LGPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2022
Last Update Date: 02/02/2022
Certification Date: 01/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11670 OLD NATIONAL PIKE STE 103
NEW MARKET MD
21774-6123
US

IV. Provider business mailing address

1211 STREAKER RD
SYKESVILLE MD
21784-8704
US

V. Phone/Fax

Practice location:
  • Phone: 301-865-2226
  • Fax: 301-865-6720
Mailing address:
  • Phone: 301-233-3485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLGP12359
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: