=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356131908
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DWAYNE R PATE JR. LMSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2025
-----------------------------------------------------
Last Update Date | 05/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 603 CRANBROOK RD APT K
-----------------------------------------------------
City | COCKEYSVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21030-3811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-564-2594
-----------------------------------------------------
Fax | 443-564-2594
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 603 CRANBROOK RD APT K
-----------------------------------------------------
City | COCKEYSVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21030-3811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-564-2594
-----------------------------------------------------
Fax | 443-564-2594
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 22004
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------