=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255850129
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PASSAGEWAYS THERAPY AND COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2017
-----------------------------------------------------
Last Update Date | 09/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 N JEFFERSON ST STE 403
-----------------------------------------------------
City | FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21701-4823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-514-4745
-----------------------------------------------------
Fax | 301-668-1854
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 N. JEFFERSON STREET SUITE 403
-----------------------------------------------------
City | FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21782-1702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-514-4745
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER
-----------------------------------------------------
Name | TAMARA LYNN KOEPP
-----------------------------------------------------
Credential | LCSW-C
-----------------------------------------------------
Telephone | 301-514-4745
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 17036
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------