Healthcare Provider Details

I. General information

NPI: 1285916593
Provider Name (Legal Business Name): MARYANNA ELIZABETH MANDERVILLE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2011
Last Update Date: 09/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2637 EASTERN BLVD
MONTGOMERY AL
36117
US

IV. Provider business mailing address

2868 ACTON ROAD
BIRMINGHAM AL
35243
US

V. Phone/Fax

Practice location:
  • Phone: 334-409-9090
  • Fax: 334-409-9669
Mailing address:
  • Phone: 205-968-8360
  • Fax: 205-968-8361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2878
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: