Provider Demographics
NPI:1164975405
Name:MULLINS, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MULLINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:20636-0129
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21155 LEXWOOD DR
Practice Address - Street 2:SUITE C
Practice Address - City:LEXINGTON PARK
Practice Address - State:MD
Practice Address - Zip Code:20653-4385
Practice Address - Country:US
Practice Address - Phone:301-373-3065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD681701700Medicaid
MD424PMedicare UPIN