Basic Information
| Provider Information | |||||||||
| NPI: | 1679021794 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACAULEY | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | LGSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7474 GREENWAY CENTER DR | ||||||||
| Address2: | |||||||||
| City: | GREENBELT | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207703504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013451022 | ||||||||
| FaxNumber: | 3015605558 | ||||||||
| Practice Location | |||||||||
| Address1: | 16220 FREDERICK RD STE 310 | ||||||||
| Address2: | |||||||||
| City: | GAITHERSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208774020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013451022 | ||||||||
| FaxNumber: | 3012966100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2016 | ||||||||
| LastUpdateDate: | 09/18/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 22172 | MD | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 104100000X | 05 | MD | MEDICAID |