Provider Demographics
NPI:1154667988
Name:EDWARD L. MISLAK, LLC
Entity Type:Organization
Organization Name:EDWARD L. MISLAK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:LEO
Authorized Official - Last Name:MISLAK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:410-893-7217
Mailing Address - Street 1:801 CHANCE CT
Mailing Address - Street 2:
Mailing Address - City:STREET
Mailing Address - State:MD
Mailing Address - Zip Code:21154-1648
Mailing Address - Country:US
Mailing Address - Phone:410-893-7217
Mailing Address - Fax:410-893-7217
Practice Address - Street 1:801 CHANCE CT
Practice Address - Street 2:
Practice Address - City:STREET
Practice Address - State:MD
Practice Address - Zip Code:21154-1648
Practice Address - Country:US
Practice Address - Phone:410-893-7217
Practice Address - Fax:410-893-7217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-26
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD081561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD031101400Medicaid
MD031101400Medicaid