Provider Demographics
NPI:1306062211
Name:IMMERGUT, REBA (LCSW-C)
Entity type:Individual
Prefix:MRS
First Name:REBA
Middle Name:
Last Name:IMMERGUT
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8901 POTOMAC STATION LN
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-3908
Mailing Address - Country:US
Mailing Address - Phone:301-656-9520
Mailing Address - Fax:302-178-3633
Practice Address - Street 1:7910 WOODMONT AVE
Practice Address - Street 2:SUITE 460
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-3002
Practice Address - Country:US
Practice Address - Phone:301-656-9520
Practice Address - Fax:301-718-3633
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD096691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD09669OtherSTATE LICENSE