Basic Information
| Provider Information | |||||||||
| NPI: | 1477881332 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRINITY PASTORAL COUNSELING CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | IS A MINISTRY OF TRINITY UNITED METHODIST CHURCH | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 703 W. PATRICK ST. | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016628908 | ||||||||
| FaxNumber: | 3016623308 | ||||||||
| Practice Location | |||||||||
| Address1: | 703 W. PATRICK ST. | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217014029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016628908 | ||||||||
| FaxNumber: | 3016623308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2009 | ||||||||
| LastUpdateDate: | 08/05/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | YOUNKINS | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | WILBUR | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR AND PASTORAL COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 3016628708 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LCPC | ||||||||
| NPICertificationDate: | 08/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | LC0744 | MD | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 101Y00000X | LC1370 | MD | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 101Y00000X | LGP315 | MD | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 101YP2500X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1699989962 | 01 | MD | BC/BS | OTHER |