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Organization
THERAPY @ 9811 INC
Active
Organization
THERAPY @ 9811 INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JACCQUELINE SOMERVILLE PSY.D., LCPC (OWNER/ CEO)
(301) 525-3205
Entity
Organization
Contact information
Practice address
9811 MALLARD DR, SUITE 210/211, LAUREL, MD 20708-3143
(301) 525-3205
Mailing address
6996 HANOVER PKWY APT 202, GREENBELT, MD 20770-2244
(443) 852-2641
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
LC2025
MD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
01217038
AMERIGROUP MEDICAID
—
01
—
1875
CAREFIRST BLUE CROSS BLUE SHIELD
—
01
—
1875-0001
CAREFIST FEP
—
05
—
413473700
—
MD
01
—
55STJE
CAREFIRST OF MARYLAND
—
01
—
676619
VALUE OPTIONS
—
01
—
7695828
AETNA (MHMO, MPPO, MEPO, MCPPO, EAP)
—
01
—
ID NUMBER IS AN NPI
TRICARE
—
01
—
ID NUMBER IS TAX ID
MHN
—
01
—
NO NUMBER ASSIGNED
CORPHEALTH
—
Enumeration date
08/27/2011
Last updated
11/01/2013
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