| Create Your Life, Llc | |
|
5008 Vane Ct Suite 2041 Waldorf MD 20602-1526 | |
| (202) 422-7337 | |
| Not Available |
| Full Name | Create Your Life, Llc |
|---|---|
| Speciality | Counselor |
| Location | 5008 Vane Ct, Waldorf, Maryland |
| Authorized Official Name and Position | Shannon Darlene Howard (LIC.CLIN. PROF. COUNSELOR) |
| Authorized Official Contact | 2024227337 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Create Your Life, Llc 5008 Vane Ct Suite 2041 Waldorf MD 20602-1526 Ph: (202) 422-7337 | Create Your Life, Llc 5008 Vane Ct Suite 2041 Waldorf MD 20602-1526 Ph: (202) 422-7337 |
| NPI Number | 1639529407 |
|---|---|
| Provider Enumeration Date | 06/13/2016 |
| Last Update Date | 06/22/2016 |
| Medicare PECOS PAC ID | 1951730381 |
|---|---|
| Medicare Enrollment ID | O20200406000733 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1639529407 | NPI | - | NPPES |
| 2132324 | Other | MD | MAMSI |
| 001437100 | Medicaid | MD | |
| 743688000 | Other | MD | MAGELLEAN |
| 60980001 | Other | DC | BLUE CROSS BLUE SHIELD |
| 358105 | Other | MD | MHN |
| 645523-03 | Other | MD | BLUE CROSS BLUE SHIELD |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YP2500X | Counselor - Professional | LC1508 (Maryland) | Primary |
| 101YP2500X | Counselor - Professional | PRC13741 (District Of Columbia) | Secondary |
| Provider Name | Andrea Michelle Williams |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1114466869 PECOS PAC ID: 0749565000 Enrollment ID: I20170329000099 |
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