Provider Demographics
NPI:1982364915
Name:MARK, MANDISHA MATTHEWS
Entity Type:Individual
Prefix:
First Name:MANDISHA
Middle Name:MATTHEWS
Last Name:MARK
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 1:513 VIA ALTOS
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-4426
Mailing Address - Country:US
Mailing Address - Phone:310-908-1233
Mailing Address - Fax:
Practice Address - Street 1:2306 GUTHRIE RD STE 260H
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043-5967
Practice Address - Country:US
Practice Address - Phone:469-290-3080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-17
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX83922101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty