Provider Demographics
NPI:1801422100
Name:DIVERSITY COUNSELING ASSOCIATES, LLC
Entity type:Organization
Organization Name:DIVERSITY COUNSELING ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:OKANUME
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC, LPC, MAC, LSWA
Authorized Official - Phone:301-814-3764
Mailing Address - Street 1:14111 MARY BOWIE PKWY
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-8572
Mailing Address - Country:US
Mailing Address - Phone:301-814-3764
Mailing Address - Fax:
Practice Address - Street 1:1300 MERCANTILE LN STE 129-17
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-5327
Practice Address - Country:US
Practice Address - Phone:301-814-3764
Practice Address - Fax:240-770-6916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-18
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD129376100Medicaid