Provider Demographics
NPI:1477991594
Name:SOUTHERN MARYLAND COUNSELING, LLC
Entity Type:Organization
Organization Name:SOUTHERN MARYLAND COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:KRAFT
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:410-231-2124
Mailing Address - Street 1:1295 HOLLIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LUSBY
Mailing Address - State:MD
Mailing Address - Zip Code:20657-2682
Mailing Address - Country:US
Mailing Address - Phone:410-231-2124
Mailing Address - Fax:410-882-1079
Practice Address - Street 1:1295 HOLLIDGE RD
Practice Address - Street 2:
Practice Address - City:LUSBY
Practice Address - State:MD
Practice Address - Zip Code:20657-2682
Practice Address - Country:US
Practice Address - Phone:410-231-2124
Practice Address - Fax:410-882-1079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-11
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC1273101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD115605500Medicaid