MEDICARE: CONNECTED SELF, 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	106H00000X	Marriage & Family Therapist	LCM130	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	361133	OTHER	MD	MHN
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932270568
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONNECTED SELF, LLC

Provider Business Mailing Address
First Line	:	3012 MITCHELLVILLE RD
Second Line	:	SUITE 103
City	:	BOWIE
State	:	MD
Zip	:	20716-3986
Country	:	US
Telephone Number	:	301-218-0836
Fax Number	:	301-218-0836

Provider Business Practice Location Address
First Line	:	3012 MITCHELLVILLE RD
Second Line	:	SUITE 103
City	:	BOWIE
State	:	MD
Zip	:	20716-3986
Country	:	US
Telephone Number	:	301-218-0836
Fax Number	:	301-218-0836

Authorized Official
Title or Position	:	OWNER, SOLE THERAPIST
Name	:	MS. MERLINA ALYCE PERKOWSKI
Credential	:	LCMFT
Telephone Number	:	301-218-0836

Provider Enumeration Date	:	11/13/2006
Last Update Date	:	03/10/2014

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Directions to “CONNECTED SELF, LLC ” Practice Location

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