Provider Demographics
NPI:1801290028
Name:SUTPHIN, MALLORY LYNNE (LCPC)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:LYNNE
Last Name:SUTPHIN
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:
Other - Last Name:BEALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:59 KATE WAGNER RD
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-6957
Mailing Address - Country:US
Mailing Address - Phone:443-244-8642
Mailing Address - Fax:410-876-3016
Practice Address - Street 1:59 KATE WAGNER RD
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-6957
Practice Address - Country:US
Practice Address - Phone:443-244-8642
Practice Address - Fax:410-876-3016
Is Sole Proprietor?:No
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC5474101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional