Provider Demographics
NPI:1720256902
Name:CLEARY, SANDRA L (LCPC)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:CLEARY
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:PO BOX 682
Mailing Address - Street 2:
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-0682
Mailing Address - Country:US
Mailing Address - Phone:410-533-2850
Mailing Address - Fax:301-226-9342
Practice Address - Street 1:41620 COURTHOUSE DRIVE
Practice Address - Street 2:SUITE 7
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650
Practice Address - Country:US
Practice Address - Phone:410-533-2850
Practice Address - Fax:301-226-9342
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-11
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC3736101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD58956180Medicaid
MD58956180Medicaid