Provider Demographics
NPI:1518356310
Name:GERVAIS, DARA (LCPC)
Entity Type:Individual
Prefix:MS
First Name:DARA
Middle Name:
Last Name:GERVAIS
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4419 FALLS RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-1226
Mailing Address - Country:US
Mailing Address - Phone:443-304-7137
Mailing Address - Fax:
Practice Address - Street 1:4419 FALLS RD
Practice Address - Street 2:SUITE A
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-1226
Practice Address - Country:US
Practice Address - Phone:443-304-7137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-16
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC7362101YM0800X
MDATG172101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health