=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851127799
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AUTHENTIC CLINICAL COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2024
-----------------------------------------------------
Last Update Date | 01/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5300 WESTVIEW DR STE 301
-----------------------------------------------------
City | FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21703-8374
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-397-9590
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5300 WESTVIEW DR STE 301
-----------------------------------------------------
City | FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21703-8374
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED CLINICAL COUNSELOR
-----------------------------------------------------
Name | LAURA WILLIAMS
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 240-397-9590
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------