Provider Demographics
NPI:1093459703
Name:CUSUMANO, MALLORI LYNNE (LLMSW)
Entity Type:Individual
Prefix:MRS
First Name:MALLORI
Middle Name:LYNNE
Last Name:CUSUMANO
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70182 PLACE RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:MI
Mailing Address - Zip Code:48062-5031
Mailing Address - Country:US
Mailing Address - Phone:231-838-7746
Mailing Address - Fax:
Practice Address - Street 1:70182 PLACE RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:MI
Practice Address - Zip Code:48062-5031
Practice Address - Country:US
Practice Address - Phone:231-838-7746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-27
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851105390104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker