Provider Demographics
NPI:1114401395
Name:USCIO, MALLORY DAWN
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:DAWN
Last Name:USCIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 W MAIN ST # 118
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIRSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43950-1040
Mailing Address - Country:US
Mailing Address - Phone:740-695-9447
Mailing Address - Fax:740-695-8895
Practice Address - Street 1:255 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SAINT CLAIRSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43950-1040
Practice Address - Country:US
Practice Address - Phone:740-695-9447
Practice Address - Fax:740-695-8895
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
OH177105101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0434035Medicaid