Basic Information
Provider Information | |||||||||
NPI: | 1609264514 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LITTLEJOHN | ||||||||
FirstName: | RENEE | ||||||||
MiddleName: | VERNELL | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6525 BELCREST RD | ||||||||
Address2: | STE G 40 | ||||||||
City: | HYATTSVILLE | ||||||||
State: | MD | ||||||||
PostalCode: | 207822003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3017798345 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 6525 BELCREST RD | ||||||||
Address2: | STE G 40 | ||||||||
City: | HYATTSVILLE | ||||||||
State: | MD | ||||||||
PostalCode: | 207822003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3017798345 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/30/2014 | ||||||||
LastUpdateDate: | 12/30/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 05767 | MD | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 999999 | 01 | MD | OTHER | OTHER | 9999999 | 01 | MD | OTHER | OTHER |