MEDICARE: MRS. TARA PISTORIO LCPC, CAC-AD

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	AC1649	MD
2	101YM0800X	Mental Health Counselor	LC9296	MD

General Provider Information

NPI Number	:	1760087837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TARA PISTORIO LCPC, CAC-AD

Provider Business Mailing Address
First Line	:	4 BRAMBLE LN
Second Line	:
City	:	CHURCHVILLE
State	:	MD
Zip	:	21028-1505
Country	:	US
Telephone Number	:	410-207-2509
Fax Number	:

Provider Business Practice Location Address
First Line	:	8600 LASALLE RD.
Second Line	:	CARROLL BUILDING, SUITE 212
City	:	TOWSON
State	:	MD
Zip	:	21286-2128
Country	:	US
Telephone Number	:	410-773-0500
Fax Number	:

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

Provider Enumeration Date	:	12/04/2020
Last Update Date	:	12/04/2020

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