MEDICARE: BALLENGER CREEK COUNSELING 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	104100000X	Social Worker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1558879148	OTHER	MD	BEHAVIORAL HEALTH

General Provider Information

NPI Number	:	1073397964
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALLENGER CREEK COUNSELING LLC

Provider Business Mailing Address
First Line	:	4305 CALVERT CIR
Second Line	:
City	:	FREDERICK
State	:	MD
Zip	:	21703-7550
Country	:	US
Telephone Number	:	240-415-8089
Fax Number	:

Provider Business Practice Location Address
First Line	:	4305 CALVERT CIR
Second Line	:
City	:	FREDERICK
State	:	MD
Zip	:	21703-7550
Country	:	US
Telephone Number	:	240-415-8089
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	CHRISTINA LYNN ROBERTS
Credential	:	LCSW-C
Telephone Number	:	240-415-8089

Provider Enumeration Date	:	08/22/2023
Last Update Date	:	08/22/2023

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