Basic Information
| Provider Information | |||||||||
| NPI: | 1225705155 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAY | ||||||||
| FirstName: | DANE | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 7474 GREENWAY CENTER DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | GREENBELT | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207703524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2403043327 | ||||||||
| FaxNumber: | 4106097091 | ||||||||
| Practice Location | |||||||||
| Address1: | 7474 GREENWAY CENTER DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | GREENBELT | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207703524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2403043327 | ||||||||
| FaxNumber: | 4106097091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2021 | ||||||||
| LastUpdateDate: | 08/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | LGP11792 | MD | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | LGP11792 | 05 | MD | MEDICAID |