=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508562679
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELA D MACK LGPC, NCC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2023
-----------------------------------------------------
Last Update Date | 02/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5000 THAYER CTR STE C
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21550-1139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 20-249-9918
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9466 GEORGIA AVE STE 2057
-----------------------------------------------------
City | SILVER SPRING
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20910-1456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-499-9188
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------