Provider Demographics
NPI:1003265257
Name:MALLORY, LAUREN (LICSW)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:MALLORY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 SEMINARY HILL RD
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-8929
Mailing Address - Country:US
Mailing Address - Phone:360-480-5388
Mailing Address - Fax:
Practice Address - Street 1:4313 6TH AVE SE STE C
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1072
Practice Address - Country:US
Practice Address - Phone:360-480-5388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-08
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
WALW610770721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker