Provider Demographics
NPI:1477192185
Name:IMPACT COUNSELING, LLC
Entity Type:Organization
Organization Name:IMPACT COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:L
Authorized Official - Middle Name:R
Authorized Official - Last Name:DOFAT-AVENT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:301-343-0463
Mailing Address - Street 1:10705 VISTA LINDA DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-4048
Mailing Address - Country:US
Mailing Address - Phone:301-343-0463
Mailing Address - Fax:
Practice Address - Street 1:4640 FORBES BLVD STE 120W
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-6320
Practice Address - Country:US
Practice Address - Phone:301-343-0463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-27
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty