Provider Demographics
NPI:1275025512
Name:DER, ANTHONY (LCPC)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:DER
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 1:6611 CAMBRIA TER
Mailing Address - Street 2:
Mailing Address - City:ELKRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21075-5952
Mailing Address - Country:US
Mailing Address - Phone:443-718-0385
Mailing Address - Fax:
Practice Address - Street 1:10705 CHARTER DR STE 410
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2800
Practice Address - Country:US
Practice Address - Phone:443-718-0385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-02
Last Update Date:2018-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC8466101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health