Provider Demographics
NPI:1770938953
Name:WATERSHED COUNSELING SERVICES, LLC
Entity type:Organization
Organization Name:WATERSHED COUNSELING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:E
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LCPC
Authorized Official - Phone:443-486-4848
Mailing Address - Street 1:PO BOX 453
Mailing Address - Street 2:
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-0453
Mailing Address - Country:US
Mailing Address - Phone:443-486-4848
Mailing Address - Fax:
Practice Address - Street 1:246 MERRIMAC COURT
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-0453
Practice Address - Country:US
Practice Address - Phone:443-486-4848
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD118121041C0700X
MDLC3657101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD298254Medicaid