Healthcare Provider Details

I. General information

NPI: 1487560942
Provider Name (Legal Business Name): KRISTIN RAE CLOUSE CAC-AD #AC3668
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 BILLINGSLEY RD
WALDORF MD
20602-3400
US

IV. Provider business mailing address

8980 DARLEY DR
LA PLATA MD
20646-3190
US

V. Phone/Fax

Practice location:
  • Phone: 855-965-5931
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberAC3668
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: