Basic Information
| Provider Information | |||||||||
| NPI: | 1306062211 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IMMERGUT | ||||||||
| FirstName: | REBA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8901 POTOMAC STATION LN | ||||||||
| Address2: | |||||||||
| City: | POTOMAC | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208543908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016569520 | ||||||||
| FaxNumber: | 3021783633 | ||||||||
| Practice Location | |||||||||
| Address1: | 7910 WOODMONT AVE | ||||||||
| Address2: | SUITE 460 | ||||||||
| City: | BETHESDA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208143002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016569520 | ||||||||
| FaxNumber: | 3017183633 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 09669 | MD | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 09669 | 01 | MD | STATE LICENSE | OTHER |