MEDICARE: SOUTHERN MARYLAND MENTAL HEALTH, 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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1548950538
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN MARYLAND MENTAL HEALTH, LLC

Provider Business Mailing Address
First Line	:	3614 11TH ST
Second Line	:
City	:	CHESAPEAKE BEACH
State	:	MD
Zip	:	20732-3130
Country	:	US
Telephone Number	:	717-873-1807
Fax Number	:

Provider Business Practice Location Address
First Line	:	3614 11TH ST
Second Line	:
City	:	CHESAPEAKE BEACH
State	:	MD
Zip	:	20732-3130
Country	:	US
Telephone Number	:	240-523-3497
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST, OWNER
Name	:	MOLLY STACKHOUSE
Credential	:	LPC
Telephone Number	:	443-218-3359

Provider Enumeration Date	:	05/11/2023
Last Update Date	:	07/23/2024

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