Provider Demographics
NPI:1104462290
Name:MCKNIGHT, POONAM (LCPC)
Entity type:Individual
Prefix:
First Name:POONAM
Middle Name:
Last Name:MCKNIGHT
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 1:11 PROCTOR AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-2633
Mailing Address - Country:US
Mailing Address - Phone:202-344-0490
Mailing Address - Fax:
Practice Address - Street 1:2905 MITCHELLVILLE RD STE 204
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-3961
Practice Address - Country:US
Practice Address - Phone:301-701-6965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-23
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP10021101Y00000X, 101YM0800X
MDLC12206101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor