Provider Demographics
NPI:1073979936
Name:AXELROD, MALLORY RUTH (LCSW)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:RUTH
Last Name:AXELROD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:RUTH
Other - Last Name:GAMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:5994 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90805-3515
Mailing Address - Country:US
Mailing Address - Phone:224-619-2640
Mailing Address - Fax:
Practice Address - Street 1:10929 SOUTH ST STE 214B
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-5374
Practice Address - Country:US
Practice Address - Phone:562-924-5526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-07
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0176341041C0700X
CAASW699671041C0700X
CALCSW723071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1922136076Medicaid