Provider Demographics
NPI:1386112894
Name:SCULLY, JANAE
Entity type:Individual
Prefix:
First Name:JANAE
Middle Name:
Last Name:SCULLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2506 FAIRHILL DR
Mailing Address - Street 2:
Mailing Address - City:SUITLAND
Mailing Address - State:MD
Mailing Address - Zip Code:20746-2304
Mailing Address - Country:US
Mailing Address - Phone:301-928-9394
Mailing Address - Fax:
Practice Address - Street 1:2506 FAIRHILL DR
Practice Address - Street 2:
Practice Address - City:SUITLAND
Practice Address - State:MD
Practice Address - Zip Code:20746-2304
Practice Address - Country:US
Practice Address - Phone:301-928-9394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-02
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC10897101YM0800X
DCLGPC00359101YM0800X
DCPRC15317101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0675007767OtherHEALTH CARE PROVIDERS SERVICE ORGANIZATION
MD0675007767OtherHSPO