Provider Demographics
NPI:1164936738
Name:REAVES, EARNEST RUSSELL (LCPC)
Entity Type:Individual
Prefix:
First Name:EARNEST
Middle Name:RUSSELL
Last Name:REAVES
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3109 EBBTIDE DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:21040-2920
Mailing Address - Country:US
Mailing Address - Phone:443-691-4982
Mailing Address - Fax:
Practice Address - Street 1:3109 EBBTIDE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:MD
Practice Address - Zip Code:21040-2920
Practice Address - Country:US
Practice Address - Phone:443-691-4982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-18
Last Update Date:2017-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC8273101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional