=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811543788
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JENNY GREY LCPC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2019
-----------------------------------------------------
Last Update Date | 08/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 208 SANDSTONE DR
-----------------------------------------------------
City | WALKERSVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21793-9146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-793-5295
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 208 SANDSTONE DR
-----------------------------------------------------
City | WALKERSVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21793-9146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-793-5295
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE OFFICER
-----------------------------------------------------
Name | JENNY GREY
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 240-793-5295
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------