Provider Demographics
NPI:1922144203
Name:MISLAK, EDWARD LEO (MSW LCSWC CACAD)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:LEO
Last Name:MISLAK
Suffix:
Gender:M
Credentials:MSW LCSWC CACAD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 CHANCE COURT
Mailing Address - Street 2:
Mailing Address - City:STREET
Mailing Address - State:MD
Mailing Address - Zip Code:21154
Mailing Address - Country:US
Mailing Address - Phone:410-893-7217
Mailing Address - Fax:410-893-7217
Practice Address - Street 1:801 CHANCE CT
Practice Address - Street 2:
Practice Address - City:STREET
Practice Address - State:MD
Practice Address - Zip Code:21154-1648
Practice Address - Country:US
Practice Address - Phone:410-893-7217
Practice Address - Fax:410-893-7217
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC1003101YA0400X
MD08156104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD031101400Medicaid
MD137882OtherVALUE OPTIONS
MD031101400Medicaid