Provider Demographics
NPI:1124443239
Name:VAN FOSSEN, MALLORY BETH (ATR-BC, LCPAT)
Entity type:Individual
Prefix:MS
First Name:MALLORY
Middle Name:BETH
Last Name:VAN FOSSEN
Suffix:
Gender:F
Credentials:ATR-BC, LCPAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8901 ROCKVILLE PIKE
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20889-0001
Mailing Address - Country:US
Mailing Address - Phone:443-340-2871
Mailing Address - Fax:
Practice Address - Street 1:8901 ROCKVILLE PIKE
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889-4268
Practice Address - Country:US
Practice Address - Phone:443-340-2871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-26
Last Update Date:2025-02-01
Deactivation Date:2015-08-11
Deactivation Code:
Reactivation Date:2020-05-22
Provider Licenses
StateLicense IDTaxonomies
MDATC054101YP2500X, 221700000X
PAPC007489101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional