Healthcare Provider Details

I. General information

NPI: 1386584886
Provider Name (Legal Business Name): ANDREA MALLOY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2026
Last Update Date: 04/01/2026
Certification Date: 04/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 MERCANTILE LN STE 208
LARGO MD
20774-5340
US

IV. Provider business mailing address

1300 MERCANTILE LN STE 208
LARGO MD
20774-5340
US

V. Phone/Fax

Practice location:
  • Phone: 301-583-0001
  • Fax: 301-583-3403
Mailing address:
  • Phone: 301-583-0001
  • Fax: 301-583-3403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGP17425
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: