Healthcare Provider Details

I. General information

NPI: 1487418513
Provider Name (Legal Business Name): MALA MANTIS COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2024
Last Update Date: 02/08/2024
Certification Date: 02/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2108 BRIGADE CIR
FREDERICK MD
21702-2502
US

IV. Provider business mailing address

2108 BRIGADE CIR
FREDERICK MD
21702-2502
US

V. Phone/Fax

Practice location:
  • Phone: 443-671-4509
  • Fax:
Mailing address:
  • Phone: 443-671-4509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LEEANN MARIE RANDOW
Title or Position: OWNER
Credential: LCSW-C
Phone: 443-671-4509