Provider Demographics
NPI:1235660457
Name:LUCID PSYCHIATRIC PRACTICE LLC
Entity Type:Organization
Organization Name:LUCID PSYCHIATRIC PRACTICE LLC
Other - Org Name:CENTERED COUNSELING SERVICES, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-351-1061
Mailing Address - Street 1:1200 E JOPPA RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-5810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 E JOPPA RD
Practice Address - Street 2:SUITE A
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286-5810
Practice Address - Country:US
Practice Address - Phone:443-632-9302
Practice Address - Fax:443-798-2772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-21
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR184691363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty