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General NPI Number Information
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NPI Number | 1114225810
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Entity Type | Organization
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Legal Business Name | LIFE THERAPY SPECIALISTS OF MD, LLC
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Dates
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Enumeration Date | 03/03/2011
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Last Update Date | 03/03/2011
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Provider Practice Location Address
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Address Line | 1927A YORK RD
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City | LUTHERVILLE
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State | MD
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Zip | 21093-4225
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Country | US
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Telephone | 443-417-4243
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Fax | 315-245-0352
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Provider Business Mailing Address
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Address Line | 1927A YORK RD
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City | LUTHERVILLE
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State | MD
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Zip | 21093-4225
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Country | US
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Telephone | 443-417-4243
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Fax | 315-245-0352
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Authorized Official
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Title or Position | PRESIDENT
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Name | MARIE E MASTRACCO
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Credential | LCPC
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Telephone | 443-417-4243
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LC2273
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License Number State | MD
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