Provider Demographics
NPI:1700654928
Name:GURUBATHAM, TATIANA MIKHAILOVNA (LGPC)
Entity Type:Individual
Prefix:MRS
First Name:TATIANA
Middle Name:MIKHAILOVNA
Last Name:GURUBATHAM
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 EVANS AVE
Mailing Address - Street 2:
Mailing Address - City:GRASONVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21638-1207
Mailing Address - Country:US
Mailing Address - Phone:240-638-6021
Mailing Address - Fax:
Practice Address - Street 1:700 MELVIN AVE STE 5
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-1506
Practice Address - Country:US
Practice Address - Phone:410-280-9444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP14320101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health