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General NPI Number Information
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NPI Number | 1376823823
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Entity Type | Organization
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Legal Business Name | THERAPY @ 9811 INC
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Dates
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Enumeration Date | 08/27/2011
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Last Update Date | 11/01/2013
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Provider Practice Location Address
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Address Line | 9811 MALLARD DR SUITE 210/211
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City | LAUREL
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State | MD
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Zip | 20708-3143
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Country | US
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Telephone | 301-525-3205
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Fax |
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Provider Business Mailing Address
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Address Line | 6996 HANOVER PKWY APT 202
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City | GREENBELT
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State | MD
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Zip | 20770-2244
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Country | US
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Telephone | 443-852-2641
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Fax |
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Authorized Official
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Title or Position | OWNER/ CEO
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Name | DR. JACCQUELINE SOMERVILLE
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Credential | PSY.D., LCPC
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Telephone | 301-525-3205
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | LC2025
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License Number State | MD
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