Healthcare Provider Details

I. General information

NPI: 1124443239
Provider Name (Legal Business Name): MALLORY BETH VAN FOSSEN ATR-BC, LCPAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2014
Last Update Date: 02/01/2025
Certification Date: 02/01/2025
Deactivation Date: 08/11/2015
Reactivation Date: 05/22/2020

III. Provider practice location address

8901 ROCKVILLE PIKE
BETHESDA MD
20889-4268
US

IV. Provider business mailing address

8901 ROCKVILLE PIKE
BETHESDA MD
20889-0001
US

V. Phone/Fax

Practice location:
  • Phone: 443-340-2871
  • Fax:
Mailing address:
  • Phone: 443-340-2871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberATC054
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC007489
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License NumberATC054
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: