Healthcare Provider Details

I. General information

NPI: 1659752608
Provider Name (Legal Business Name): VICTORIA KAI STITH L.C.P.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2015
Last Update Date: 11/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W CHESAPEAKE AVE SUITE L12
TOWSON MD
21204-4421
US

IV. Provider business mailing address

205 N TYRONE RD
BALTIMORE MD
21212-1124
US

V. Phone/Fax

Practice location:
  • Phone: 410-241-1238
  • Fax:
Mailing address:
  • Phone: 410-241-1238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLC6502
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC6502
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC6502
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: