Healthcare Provider Details

I. General information

NPI: 1528683414
Provider Name (Legal Business Name): JACQUELINE BAMBIL LGPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2020
Last Update Date: 11/20/2023
Certification Date: 11/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10624 KNOLLWOOD CT
WALDORF MD
20603-3235
US

IV. Provider business mailing address

10624 KNOLLWOOD CT
WALDORF MD
20603-3235
US

V. Phone/Fax

Practice location:
  • Phone: 571-241-0254
  • Fax: 484-393-4096
Mailing address:
  • Phone: 571-241-0254
  • Fax: 484-393-4096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC12823
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPRC200001582
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: