MEDICARE: WYE OAK THERAPEUTIC SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency
2	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1063073450
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WYE OAK THERAPEUTIC SERVICES, LLC

Provider Business Mailing Address
First Line	:	165 LOG CANOE CIR STE B-3
Second Line	:
City	:	STEVENSVILLE
State	:	MD
Zip	:	21666-2149
Country	:	US
Telephone Number	:	443-249-3351
Fax Number	:

Provider Business Practice Location Address
First Line	:	165 LOG CANOE CIR STE B-3
Second Line	:
City	:	STEVENSVILLE
State	:	MD
Zip	:	21666-2149
Country	:	US
Telephone Number	:	443-249-3351
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PSYCHOTHERAPIST
Name	:	CRYSTAL R BLANCHARD
Credential	:	LCPC
Telephone Number	:	443-249-2601

Provider Enumeration Date	:	06/26/2019
Last Update Date	:	04/03/2023

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