Healthcare Provider Details

I. General information

NPI: 1447950381
Provider Name (Legal Business Name): TINA CORNISH LAURY LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2023
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2670 CRAIN HWY STE 205
WALDORF MD
20601-2816
US

IV. Provider business mailing address

2670 CRAIN HWY STE 205
WALDORF MD
20601-2816
US

V. Phone/Fax

Practice location:
  • Phone: 301-818-0092
  • Fax:
Mailing address:
  • Phone: 301-818-0092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGP12397
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC16578
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: