Healthcare Provider Details

I. General information

NPI: 1770938953
Provider Name (Legal Business Name): WATERSHED COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2016
Last Update Date: 04/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

246 MERRIMAC COURT
PRINCE FREDERICK MD
20678-0453
US

IV. Provider business mailing address

PO BOX 453
PRINCE FREDERICK MD
20678-0453
US

V. Phone/Fax

Practice location:
  • Phone: 443-486-4848
  • Fax:
Mailing address:
  • Phone: 443-486-4848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC3657
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11812
License Number StateMD

VIII. Authorized Official

Name: DR. KAREN E RAY
Title or Position: DIRECTOR
Credential: PH.D., LCPC
Phone: 443-486-4848