Healthcare Provider Details

I. General information

NPI: 1073215000
Provider Name (Legal Business Name): CARRIE WILLIAMS LGPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARRIE RAYNE

II. Dates (important events)

Enumeration Date: 03/21/2023
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4425 FITCH AVE STE 118
NOTTINGHAM MD
21236-3927
US

IV. Provider business mailing address

4425 FITCH AVE STE 118
NOTTINGHAM MD
21236-3927
US

V. Phone/Fax

Practice location:
  • Phone: 410-870-2125
  • Fax:
Mailing address:
  • Phone: 410-870-2125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGP11694
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: