=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720618044
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAUREN A REIDER LCSW-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2020
-----------------------------------------------------
Last Update Date | 01/26/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 770 RITCHIE HWY STE W16
-----------------------------------------------------
City | SEVERNA PARK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21146-4158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-294-0152
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 137 CALHOUN ST
-----------------------------------------------------
City | EDGEWATER
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21037-1634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-852-6578
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 19999
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------