MEDICARE: KRISTEN CLARK PILGRIM 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	101YM0800X	Mental Health Counselor	LC16561	MD
2	101200000X	Drama Therapist	RDT804

General Provider Information

NPI Number	:	1588234629
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTEN CLARK PILGRIM LCPC

Provider Business Mailing Address
First Line	:	1707 62ND AVE
Second Line	:
City	:	CHEVERLY
State	:	MD
Zip	:	20785-3806
Country	:	US
Telephone Number	:	804-380-6552
Fax Number	:

Provider Business Practice Location Address
First Line	:	10810 DARNESTOWN RD STE 103
Second Line	:
City	:	NORTH POTOMAC
State	:	MD
Zip	:	20878-2604
Country	:	US
Telephone Number	:	301-869-1017
Fax Number	:

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

Provider Enumeration Date	:	06/30/2021
Last Update Date	:	01/27/2026

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