Healthcare Provider Details

I. General information

NPI: 1922509421
Provider Name (Legal Business Name): LAURA REAGAN LCSW-C PSYCHOTHERAPY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2018
Last Update Date: 02/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 BALTIMORE ANNAPOLIS BLVD STE 220
SEVERNA PARK MD
21146-3934
US

IV. Provider business mailing address

645 BALTIMORE ANNAPOLIS BLVD STE 220
SEVERNA PARK MD
21146-3934
US

V. Phone/Fax

Practice location:
  • Phone: 703-402-1551
  • Fax: 703-402-1551
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: TORI MATTON
Title or Position: THERAPIST
Credential:
Phone: 703-402-1551