Provider Demographics
NPI:1912043142
Name:MADER, MANDI CHAPMAN (LCSW-C)
Entity Type:Individual
Prefix:
First Name:MANDI
Middle Name:CHAPMAN
Last Name:MADER
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11307 ROKEBY AVE
Mailing Address - Street 2:PO BOX 187
Mailing Address - City:GARRETT PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20896-1514
Mailing Address - Country:US
Mailing Address - Phone:301-466-1637
Mailing Address - Fax:
Practice Address - Street 1:11307 ROKEBY AVE
Practice Address - Street 2:
Practice Address - City:GARRETT PARK
Practice Address - State:MD
Practice Address - Zip Code:20896-1514
Practice Address - Country:US
Practice Address - Phone:301-466-1637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD110231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
55-0917325OtherEIN