Provider Demographics
NPI:1104219971
Name:BARRETT, MALLORY SUZANNE (MSW, LMSW)
Entity Type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:SUZANNE
Last Name:BARRETT
Suffix:
Gender:F
Credentials:MSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 BALL AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-5904
Mailing Address - Country:US
Mailing Address - Phone:616-456-6571
Mailing Address - Fax:616-235-0979
Practice Address - Street 1:238 HOOVER BLVD STE 30
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3782
Practice Address - Country:US
Practice Address - Phone:616-312-2989
Practice Address - Fax:616-294-4202
Is Sole Proprietor?:No
Enumeration Date:2015-03-18
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801117532101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health