Healthcare Provider Details

I. General information

NPI: 1194474700
Provider Name (Legal Business Name): MANDY KAY SPROUL MAAT, LPC, ATR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2022
Last Update Date: 02/23/2024
Certification Date: 02/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BACKROAD
MADRID NM
87010-9727
US

IV. Provider business mailing address

1 BACKROAD
MADRID NM
87010-9727
US

V. Phone/Fax

Practice location:
  • Phone: 515-996-0278
  • Fax:
Mailing address:
  • Phone: 515-996-0278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC.00181015
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: