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General NPI Number Information
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NPI Number | 1164165056
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Entity Type | Individual
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Provider Name | TAYLOR CHARISSE KENNERLY LGPC
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Gender | Female
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Dates
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Enumeration Date | 04/18/2022
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Last Update Date | 04/18/2022
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Provider Practice Location Address
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Address Line | 3261 OLD WASHINGTON RD STE 3021
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City | WALDORF
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State | MD
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Zip | 20602-3229
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Country | US
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Telephone | 240-280-3245
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Fax |
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Provider Business Mailing Address
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Address Line | 4351 TELFAIR BLVD APT G101
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City | CAMP SPRINGS
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State | MD
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Zip | 20746-4285
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Country | US
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Telephone | 203-216-4252
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | LGP11841
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License Number State | MD
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