Healthcare Provider Details

I. General information

NPI: 1053798470
Provider Name (Legal Business Name): MAMATA HOTHA LGSW, LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2015
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15701 CRABBS BRANCH WAY
ROCKVILLE MD
20855-2634
US

IV. Provider business mailing address

15701 CRABBS BRANCH WAY
ROCKVILLE MD
20855-2634
US

V. Phone/Fax

Practice location:
  • Phone: 917-574-1240
  • Fax: 301-365-2590
Mailing address:
  • Phone: 917-574-1240
  • Fax: 301-365-2590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number0903002152
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number20109
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: