Provider Demographics
NPI:1336611912
Name:PRODIGY COUNSELING SERVICES
Entity type:Organization
Organization Name:PRODIGY COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:ASIA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:443-577-8959
Mailing Address - Street 1:8718 GILLY WAY
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-5310
Mailing Address - Country:US
Mailing Address - Phone:443-577-8959
Mailing Address - Fax:
Practice Address - Street 1:17 WARREN RD
Practice Address - Street 2:
Practice Address - City:PIKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21208-5334
Practice Address - Country:US
Practice Address - Phone:443-577-8959
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD262005700Medicaid