Provider Demographics
NPI:1548001837
Name:DE MATOS MEDEIROS, MARIANA (LMSW)
Entity type:Individual
Prefix:
First Name:MARIANA
Middle Name:
Last Name:DE MATOS MEDEIROS
Suffix:
Gender:X
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7336 EDEN BROOK DR APT 1017
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21046-1146
Mailing Address - Country:US
Mailing Address - Phone:443-977-8280
Mailing Address - Fax:
Practice Address - Street 1:7336 EDEN BROOK DR APT 1017
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-1146
Practice Address - Country:US
Practice Address - Phone:443-977-8280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-03
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD30854101YM0800X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health