Provider Demographics
NPI:1073153672
Name:GROBE, MALLORY NICOLE (LMSW-CC)
Entity Type:Individual
Prefix:MISS
First Name:MALLORY
Middle Name:NICOLE
Last Name:GROBE
Suffix:
Gender:F
Credentials:LMSW-CC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 ALFRED ST
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-3102
Mailing Address - Country:US
Mailing Address - Phone:802-281-2018
Mailing Address - Fax:
Practice Address - Street 1:314 ALFRED ST
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-3102
Practice Address - Country:US
Practice Address - Phone:802-281-2018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC18174101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health