Provider Demographics
NPI:1073274387
Name:LAVENDER, DE'TRECE ATALIE (NCC, LGPC)
Entity Type:Individual
Prefix:
First Name:DE'TRECE
Middle Name:ATALIE
Last Name:LAVENDER
Suffix:
Gender:F
Credentials:NCC, LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 PARKWYRTH AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-1956
Mailing Address - Country:US
Mailing Address - Phone:443-522-8113
Mailing Address - Fax:
Practice Address - Street 1:8101 SANDY SPRING RD STE 250
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-3527
Practice Address - Country:US
Practice Address - Phone:667-228-8397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-07
Last Update Date:2022-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP12232101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty