Provider Demographics
NPI:1760858823
Name:GARMODEH, MAILLA
Entity Type:Individual
Prefix:
First Name:MAILLA
Middle Name:
Last Name:GARMODEH
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 1:711 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:PA
Mailing Address - Zip Code:19007-6473
Mailing Address - Country:US
Mailing Address - Phone:347-552-8695
Mailing Address - Fax:
Practice Address - Street 1:711 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:PA
Practice Address - Zip Code:19007-6473
Practice Address - Country:US
Practice Address - Phone:347-552-6823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health