Provider Demographics
NPI:1376823823
Name:THERAPY @ 9811 INC
Entity Type:Organization
Organization Name:THERAPY @ 9811 INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JACCQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SOMERVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LCPC
Authorized Official - Phone:301-525-3205
Mailing Address - Street 1:6996 HANOVER PKWY APT 202
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-2244
Mailing Address - Country:US
Mailing Address - Phone:443-852-2641
Mailing Address - Fax:
Practice Address - Street 1:9811 MALLARD DR
Practice Address - Street 2:SUITE 210/211
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20708-3143
Practice Address - Country:US
Practice Address - Phone:301-525-3205
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-27
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC2025101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID NUMBER IS TAX IDOtherMHN
1875OtherCAREFIRST BLUE CROSS BLUE SHIELD
MD413473700Medicaid
676619OtherVALUE OPTIONS
NO NUMBER ASSIGNEDOtherCORPHEALTH
676619OtherUNITED BEHAVIORAL HEALTH
NO NUMBER ASSIGNEDOtherCERIDIAN EAP
01217038OtherAMERIGROUP MEDICAID
1875-0001OtherCAREFIST FEP
ID NUMBER IS AN NPIOtherTRICARE
NO NUMBER ASSIGNEDOtherFIRST ADVANTAGE EAP
NO NUMBER ASSIGNEDOtherCAREBRIDGE EAP
NO NUMBER ASSIGNEDOtherINOVA EAP
55STJEOtherCAREFIRST OF MARYLAND
7695828OtherAETNA (MHMO, MPPO, MEPO, MCPPO, EAP)