Provider Demographics
NPI:1326514308
Name:MALLIK, MOUSUMI (MA)
Entity Type:Individual
Prefix:
First Name:MOUSUMI
Middle Name:
Last Name:MALLIK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 TANGLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-4478
Mailing Address - Country:US
Mailing Address - Phone:419-410-7874
Mailing Address - Fax:
Practice Address - Street 1:2211 RIVER RD
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-3637
Practice Address - Country:US
Practice Address - Phone:419-740-3052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-17
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.2303491101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional