MEDICARE: EMOTIONAL ABUSE SUPPORT TEAM

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	1041C0700X	Clinical Social Worker
2	101YP2500X	Professional Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1205355344	OTHER	MD	NPI
2	1023663325	OTHER	MD	NPI
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336731116
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMOTIONAL ABUSE SUPPORT TEAM

Provider Business Mailing Address
First Line	:	1808 61ST AVE
Second Line	:
City	:	CHEVERLY
State	:	MD
Zip	:	20785-3803
Country	:	US
Telephone Number	:	240-319-0182
Fax Number	:

Provider Business Practice Location Address
First Line	:	1808 61ST AVE
Second Line	:
City	:	CHEVERLY
State	:	MD
Zip	:	20785-3803
Country	:	US
Telephone Number	:	240-319-0182
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE
Name	:	DEMAREST CRAWL
Credential	:	LCSW-C
Telephone Number	:	240-319-0182

Provider Enumeration Date	:	02/03/2021
Last Update Date	:	02/03/2021

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