MEDICARE: DUSTIN MENICK LCPC

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	101YP2500X	Professional Counselor	LC4885	MD

General Provider Information

NPI Number	:	1316324130
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DUSTIN MENICK LCPC

Provider Business Mailing Address
First Line	:	8309 SNUG HILL LN
Second Line	:
City	:	POTOMAC
State	:	MD
Zip	:	20854-4057
Country	:	US
Telephone Number	:	301-257-8833
Fax Number	:

Provider Business Practice Location Address
First Line	:	4815 SAINT ELMO AVE
Second Line	:	SUITE 100
City	:	BETHESDA
State	:	MD
Zip	:	20814-7061
Country	:	US
Telephone Number	:	301-257-8833
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/30/2015
Last Update Date	:	04/30/2015

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