Provider Demographics
NPI:1275088601
Name:GOLDMAN, MALLORY (LCSW)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:GOLDMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 DUMBARTON RD
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23228-6100
Mailing Address - Country:US
Mailing Address - Phone:804-307-2801
Mailing Address - Fax:
Practice Address - Street 1:2000 DUMBARTON RD
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23228-6100
Practice Address - Country:US
Practice Address - Phone:804-307-2801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-15
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904009351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical