=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386327500
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | G.E.M.S. PSYCHOTHERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2023
-----------------------------------------------------
Last Update Date | 08/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8056 MONTAGUE CT
-----------------------------------------------------
City | GLEN BURNIE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21061-4912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-306-3394
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8056 MONTAGUE CT
-----------------------------------------------------
City | GLEN BURNIE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21061-4912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-306-3394
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOTHERAPIST
-----------------------------------------------------
Name | MS. TAKEA JOHNSON
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 443-306-3394
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------