Provider Demographics
NPI:1669347449
Name:TOMLJANOVICH, LYRA GRACE
Entity type:Individual
Prefix:
First Name:LYRA
Middle Name:GRACE
Last Name:TOMLJANOVICH
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 1:1460 RITCHIE HWY STE 201
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MD
Mailing Address - Zip Code:21012-2741
Mailing Address - Country:US
Mailing Address - Phone:703-828-5147
Mailing Address - Fax:
Practice Address - Street 1:1460 RITCHIE HWY STE 201
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MD
Practice Address - Zip Code:21012-2741
Practice Address - Country:US
Practice Address - Phone:703-828-5147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-09
Last Update Date:2025-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP16854101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health