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General NPI Number Information
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NPI Number | 1982364915
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Entity Type | Individual
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Provider Name | MANDISHA MATTHEWS MARK
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Gender | Female
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Dates
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Enumeration Date | 12/17/2021
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Last Update Date | 12/17/2021
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Provider Practice Location Address
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Address Line | 2306 GUTHRIE RD STE 260H
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City | GARLAND
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State | TX
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Zip | 75043-5967
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Country | US
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Telephone | 469-290-3080
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Fax |
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Provider Business Mailing Address
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Address Line | 513 VIA ALTOS
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City | MESQUITE
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State | TX
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Zip | 75150-4426
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Country | US
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Telephone | 310-908-1233
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 83922
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License Number State | TX
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