Provider Demographics
NPI:1114570611
Name:GAYLE, DIANA ANDREA (LGPC)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:ANDREA
Last Name:GAYLE
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19619 CRYSTAL ROCK DR APT 23
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20874-4862
Mailing Address - Country:US
Mailing Address - Phone:240-264-9819
Mailing Address - Fax:
Practice Address - Street 1:4500 BLACK ROCK RD STE 103
Practice Address - Street 2:
Practice Address - City:HAMPSTEAD
Practice Address - State:MD
Practice Address - Zip Code:21074-2649
Practice Address - Country:US
Practice Address - Phone:877-806-1501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MDLGP13409101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician