Provider Demographics
NPI:1073973897
Name:BATHURST, STEPHANIE P (MA, LCMFT)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:P
Last Name:BATHURST
Suffix:
Gender:F
Credentials:MA, LCMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 DEEP POWDER COURT
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:MD
Mailing Address - Zip Code:21163
Mailing Address - Country:US
Mailing Address - Phone:215-692-2461
Mailing Address - Fax:
Practice Address - Street 1:12501 PROSPERITY DR STE 310
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-1699
Practice Address - Country:US
Practice Address - Phone:240-780-8884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-07
Last Update Date:2020-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGM501106H00000X
MDLCM585106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist