Provider Demographics
NPI:1396174785
Name:SOUVENIR, PRINCESS (LCPC)
Entity type:Individual
Prefix:DR
First Name:PRINCESS
Middle Name:
Last Name:SOUVENIR
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 1:11720 BELTSVILLE DR STE 500-A4
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-3166
Mailing Address - Country:US
Mailing Address - Phone:240-755-8089
Mailing Address - Fax:
Practice Address - Street 1:3909 NATIONAL DR STE 100
Practice Address - Street 2:
Practice Address - City:BURTONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20866-1192
Practice Address - Country:US
Practice Address - Phone:240-755-8089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-05
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MDLGP8593101YP2500X
MDLC10330101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1396174785Medicaid