Provider Demographics
NPI:1245701119
Name:INTEGRATED COUNSELING PROFESSIONALS LLC
Entity type:Organization
Organization Name:INTEGRATED COUNSELING PROFESSIONALS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER / CLINICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:EARNEST
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:REAVES
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:443-691-4982
Mailing Address - Street 1:1614 E. CHURCHVILLE RD
Mailing Address - Street 2:STE 101A
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21015-2050
Mailing Address - Country:US
Mailing Address - Phone:443-372-8573
Mailing Address - Fax:
Practice Address - Street 1:1614 E. CHURCHVILLE RD
Practice Address - Street 2:STE 101A
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21015-2050
Practice Address - Country:US
Practice Address - Phone:443-372-8573
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1164936738OtherINSURERS