Healthcare Provider Details

I. General information

NPI: 1023786654
Provider Name (Legal Business Name): MORDECAI ANDEMICHAEL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2021
Last Update Date: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4413 REAMY DR
SUITLAND MD
20746-3745
US

IV. Provider business mailing address

4413 REAMY DR
SUITLAND MD
20746-3745
US

V. Phone/Fax

Practice location:
  • Phone: 301-244-9131
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MORDECAI ANDEMICHAEL
Title or Position: THERAPIST
Credential:
Phone: 240-476-2629