Provider Demographics
NPI:1518443274
Name:LAVENDER HILLS PSYCHOTHERAPY LLC
Entity Type:Organization
Organization Name:LAVENDER HILLS PSYCHOTHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRIQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:240-230-6668
Mailing Address - Street 1:11140 ROCKVILLE PIKE STE 400
Mailing Address - Street 2:
Mailing Address - City:N BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20852-3104
Mailing Address - Country:US
Mailing Address - Phone:240-230-6668
Mailing Address - Fax:
Practice Address - Street 1:11140 ROCKVILLE PIKE STE 400
Practice Address - Street 2:
Practice Address - City:NORTH BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20852-3104
Practice Address - Country:US
Practice Address - Phone:240-230-6668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-16
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05723103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1598071433OtherCLINICAL PSYCHOLOGIST