Provider Demographics
NPI:1467178053
Name:BRIARD VANTELAS, MARIE MARCELLE (LGPC, ADT)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:MARCELLE
Last Name:BRIARD VANTELAS
Suffix:
Gender:F
Credentials:LGPC, ADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 BISHOP WALSH RD
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-1802
Mailing Address - Country:US
Mailing Address - Phone:732-850-5977
Mailing Address - Fax:
Practice Address - Street 1:907 SETON DR
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-1817
Practice Address - Country:US
Practice Address - Phone:301-777-0633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-14
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDADT2497101YA0400X
MDLGP13227101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)