Provider Demographics
NPI:1285177600
Name:SOUTHERN MARYLAND COUNSELING & COACHING, LLC
Entity type:Organization
Organization Name:SOUTHERN MARYLAND COUNSELING & COACHING, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAVIDRA
Authorized Official - Middle Name:T
Authorized Official - Last Name:BAZEMORE-BLUE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:202-997-6060
Mailing Address - Street 1:16705 ROLLING TREE RD
Mailing Address - Street 2:
Mailing Address - City:ACCOKEEK
Mailing Address - State:MD
Mailing Address - Zip Code:20607-3358
Mailing Address - Country:US
Mailing Address - Phone:202-997-6060
Mailing Address - Fax:
Practice Address - Street 1:3261 OLD WASHINGTON RD STE 2020
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-3231
Practice Address - Country:US
Practice Address - Phone:240-435-4708
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-02
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD191141041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty