Provider Demographics
NPI:1073027538
Name:KIERNAN, MALLORY (APSW)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:KIERNAN
Suffix:
Gender:F
Credentials:APSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 S RIVER ST STE 254
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-3863
Mailing Address - Country:US
Mailing Address - Phone:608-755-5260
Mailing Address - Fax:608-755-5267
Practice Address - Street 1:778 LOIS DR
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-1100
Practice Address - Country:US
Practice Address - Phone:608-755-5260
Practice Address - Fax:608-755-5267
Is Sole Proprietor?:No
Enumeration Date:2017-11-20
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI130860104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker