Basic Information
| Provider Information | |||||||||
| NPI: | 1417512252 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELDER | ||||||||
| FirstName: | IRENE | ||||||||
| MiddleName: | LORRAINE | ||||||||
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| Credential: | LCPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12131 ELM FOREST CT APT H | ||||||||
| Address2: | |||||||||
| City: | CLARKSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208716320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017875423 | ||||||||
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| Practice Location | |||||||||
| Address1: | 17904 GEORGIA AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | OLNEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208322277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2403043327 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2019 | ||||||||
| LastUpdateDate: | 07/08/2019 | ||||||||
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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 | 101YM0800X | LC8980 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.