Healthcare Provider Details

I. General information

NPI: 1295422798
Provider Name (Legal Business Name): JUSTINE LASHAWN DE LA GARZA LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 04/24/2023
Certification Date: 04/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 SOLOMONS ISLAND RD N STE 119
PRINCE FREDERICK MD
20678-3917
US

IV. Provider business mailing address

PO BOX 980
PRINCE FREDERICK MD
20678-0980
US

V. Phone/Fax

Practice location:
  • Phone: 410-535-5400
  • Fax: 410-535-2220
Mailing address:
  • Phone: 410-535-3079
  • Fax: 410-535-2220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: