Basic Information
| Provider Information | |||||||||
| NPI: | 1063719060 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRYANT-MALLORY | ||||||||
| FirstName: | DEITRA | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LICSW, LCSW-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4014 WALES LN | ||||||||
| Address2: | |||||||||
| City: | UPPER MARLBORO | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207727997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2404629283 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10001 DEREKWOOD LN STE 120 | ||||||||
| Address2: | |||||||||
| City: | LANHAM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207064876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013064590 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2011 | ||||||||
| LastUpdateDate: | 02/28/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 13673 | MD | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | LC50078061 | DC | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.