Provider Demographics
NPI:1043628555
Name:MOLLE, MALLORY LORRAINE (MS)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:LORRAINE
Last Name:MOLLE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6521
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90734-6521
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:555 W 9TH ST STE 5
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3157
Practice Address - Country:US
Practice Address - Phone:424-287-7567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-28
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA97620106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist