Provider Demographics
NPI:1447950381
Name:LAURY, TINA CORNISH (LGPC)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:CORNISH
Last Name:LAURY
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 PINE RD
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-6616
Mailing Address - Country:US
Mailing Address - Phone:301-641-0598
Mailing Address - Fax:
Practice Address - Street 1:505 PINE RD
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-6616
Practice Address - Country:US
Practice Address - Phone:301-641-0598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-08
Last Update Date:2023-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP12397101YM0800X
MDLG12397101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health