Healthcare Provider Details

I. General information

NPI: 1437375615
Provider Name (Legal Business Name): RONALD GRAY MEDLIN, INSTITUTE OF LIFE AND HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 03/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5311 WATER ST SUITE D
UPPER MARLBORO MD
20772-3056
US

IV. Provider business mailing address

5311 WATER ST SUITE D
UPPER MARLBORO MD
20772-3056
US

V. Phone/Fax

Practice location:
  • Phone: 301-627-3007
  • Fax:
Mailing address:
  • Phone: 301-627-3007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberLCA352
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCA352
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCA352
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLCA352
License Number StateMD
# 5
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberLCA352
License Number StateMD
# 6
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberLCA352
License Number StateMD
# 7
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License NumberLCA352
License Number StateMD
# 8
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLCA352
License Number StateMD

VIII. Authorized Official

Name: DR. RONALD GRAY MEDLIN
Title or Position: OWNER,PROGRAM DIRECTOR
Credential: PH.D., LCADC
Phone: 301-627-3007