1063719060 NPI number — MS. DEITRA E. BRYANT-MALLORY LICSW, LCSW-C

Table of content: LU TIAN (NPI 1700767456)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063719060 NPI number — MS. DEITRA E. BRYANT-MALLORY LICSW, LCSW-C

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
BRYANT-MALLORY

Provider First Name:
DEITRA

Provider Middle Name:
E.

Provider Name Prefix Text:
MS.

Provider Name Suffix Text:

Provider Credential Text:
LICSW, LCSW-C

Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063719060

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
02/28/2011

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4014 WALES LN

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:
UPPER MARLBORO

Provider Business Mailing Address State Name:
MD

Provider Business Mailing Address Postal Code:
20772-7997

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
240-462-9283

Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10001 DEREKWOOD LN STE 120

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:
LANHAM

Provider Business Practice Location Address State Name:
MD

Provider Business Practice Location Address Postal Code:
20706-4876

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
301-306-4590

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:
02/28/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

Provider Taxonomy Codes

Taxonomy code: 1041C0700X , with the licence number: 13673 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Taxonomy code: 1041C0700X , with the licence number: LC50078061 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .