Healthcare Provider Details

I. General information

NPI: 1356803415
Provider Name (Legal Business Name): TRACY ANN-MARIE LAXTON LCSWC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 04/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9627 PHILADELPHIA RD STE 160
ROSEDALE MD
21237-4157
US

IV. Provider business mailing address

9627 PHILADELPHIA RD STE 160
ROSEDALE MD
21237-4157
US

V. Phone/Fax

Practice location:
  • Phone: 410-780-4320
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number20030
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: