Provider Demographics
NPI:1679021794
Name:MACAULEY, MARK (LGSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MACAULEY
Suffix:
Gender:M
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7474 GREENWAY CENTER DR
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-3504
Mailing Address - Country:US
Mailing Address - Phone:301-345-1022
Mailing Address - Fax:301-560-5558
Practice Address - Street 1:16220 FREDERICK RD STE 310
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-4020
Practice Address - Country:US
Practice Address - Phone:301-345-1022
Practice Address - Fax:301-296-6100
Is Sole Proprietor?:No
Enumeration Date:2016-09-18
Last Update Date:2016-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD221721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD104100000XMedicaid