=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770938953
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WATERSHED COUNSELING SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2016
-----------------------------------------------------
Last Update Date | 04/26/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 246 MERRIMAC COURT
-----------------------------------------------------
City | PRINCE FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20678-0453
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-486-4848
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 453
-----------------------------------------------------
City | PRINCE FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20678-0453
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-486-4848
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DR. KAREN E RAY
-----------------------------------------------------
Credential | PH.D., LCPC
-----------------------------------------------------
Telephone | 443-486-4848
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 11812
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LC3657
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------