Provider Demographics
NPI:1033173406
Name:MALLOY, MARY L A (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARY L
Middle Name:A
Last Name:MALLOY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18360-2499
Mailing Address - Country:US
Mailing Address - Phone:570-476-6460
Mailing Address - Fax:570-476-6466
Practice Address - Street 1:411 MAIN ST
Practice Address - Street 2:
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-2499
Practice Address - Country:US
Practice Address - Phone:570-476-6460
Practice Address - Fax:570-476-6466
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0122001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA634581Medicare ID - Type Unspecified