Provider Demographics
NPI:1760153407
Name:MANDELBERG, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:MANDELBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:MANDELBERG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LGPC
Mailing Address - Street 1:1430 LAWRENCE ST APT 407
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-5595
Mailing Address - Country:US
Mailing Address - Phone:443-878-6900
Mailing Address - Fax:
Practice Address - Street 1:6501 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-6819
Practice Address - Country:US
Practice Address - Phone:410-927-5462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP11936101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional