Provider Demographics
NPI:1720809197
Name:HARDISTY, JANYL (LGPC)
Entity type:Individual
Prefix:
First Name:JANYL
Middle Name:
Last Name:HARDISTY
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 DOVETAIL LN
Mailing Address - Street 2:
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-1355
Mailing Address - Country:US
Mailing Address - Phone:443-534-3734
Mailing Address - Fax:
Practice Address - Street 1:43 COMMUNITY PL
Practice Address - Street 2:
Practice Address - City:CROWNSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21032-2034
Practice Address - Country:US
Practice Address - Phone:410-571-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-18
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP15616101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor