Provider Demographics
NPI:1083085963
Name:PRICE, MALLORY (AM, LCSW)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:PRICE
Suffix:
Gender:F
Credentials:AM, LCSW
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:ANN
Other - Last Name:PRICE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:AM, LCSW
Mailing Address - Street 1:5300 S SHORE DR STE 201
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-5777
Mailing Address - Country:US
Mailing Address - Phone:708-320-1828
Mailing Address - Fax:
Practice Address - Street 1:5300 S SHORE DR STE 201
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-5777
Practice Address - Country:US
Practice Address - Phone:708-320-1828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-17
Last Update Date:2022-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490172611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical