Provider Demographics
NPI:1720576259
Name:MAMOLOU, ALEXANDRA (LPC)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:MAMOLOU
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2483 INDEPENDENCE AVE
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:PA
Mailing Address - Zip Code:19001-3135
Mailing Address - Country:US
Mailing Address - Phone:215-869-0921
Mailing Address - Fax:
Practice Address - Street 1:2401 PENNSYLVANIA AVE STE 1C52
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-7723
Practice Address - Country:US
Practice Address - Phone:802-780-0101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC009640101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional