Provider Demographics
NPI:1053167262
Name:MCCONNELL, GAVIN ELIJAH (LGPC)
Entity type:Individual
Prefix:MR
First Name:GAVIN
Middle Name:ELIJAH
Last Name:MCCONNELL
Suffix:
Gender:M
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:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:GRANTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21536-0158
Mailing Address - Country:US
Mailing Address - Phone:240-956-9650
Mailing Address - Fax:
Practice Address - Street 1:1025 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:MD
Practice Address - Zip Code:21550-4343
Practice Address - Country:US
Practice Address - Phone:301-334-7680
Practice Address - Fax:301-334-7681
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-29
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP15013101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health