=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982827754
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH PARK FAMILY CONSULTATION CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4C NORTH AVE SUITE 403
-----------------------------------------------------
City | BEL AIR
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21014-2330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-638-7088
-----------------------------------------------------
Fax | 410-838-6453
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4C NORTH AVE SUITE 403
-----------------------------------------------------
City | BEL AIR
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21014-2330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-638-7088
-----------------------------------------------------
Fax | 410-838-6453
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GREGORY E. SMITH
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 410-638-7088
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------