Provider Demographics
NPI:1104061258
Name:MAINSTREET COUNSELING SERVICES, LLC
Entity type:Organization
Organization Name:MAINSTREET COUNSELING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:ANGELLA
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, APRN-BC
Authorized Official - Phone:301-627-6816
Mailing Address - Street 1:14514 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-3059
Mailing Address - Country:US
Mailing Address - Phone:301-627-6816
Mailing Address - Fax:
Practice Address - Street 1:14514 MAIN ST
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-3059
Practice Address - Country:US
Practice Address - Phone:301-627-6816
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-03
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRN117769101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty