Healthcare Provider Details

I. General information

NPI: 1952158990
Provider Name (Legal Business Name): ANDREA T GOUNDRY LGPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANDI ADOLPH

II. Dates (important events)

Enumeration Date: 05/06/2024
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9649 BELAIR RD STE 104
NOTTINGHAM MD
21236-1117
US

IV. Provider business mailing address

4 BELFAST RD
LUTHERVILLE TIMONIUM MD
21093-4201
US

V. Phone/Fax

Practice location:
  • Phone: 410-529-1309
  • Fax:
Mailing address:
  • Phone: 717-497-8309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGP14111
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: