Provider Demographics
NPI:1275742520
Name:MALLERY, BERRELL (PHD)
Entity Type:Individual
Prefix:
First Name:BERRELL
Middle Name:
Last Name:MALLERY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 WEST HOUSTON STREET
Mailing Address - Street 2:1E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10014
Mailing Address - Country:US
Mailing Address - Phone:646-498-5420
Mailing Address - Fax:212-228-2146
Practice Address - Street 1:180 WEST HOUSTON STREET
Practice Address - Street 2:1E
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10014
Practice Address - Country:US
Practice Address - Phone:646-498-5420
Practice Address - Fax:212-228-2146
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7352103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7352OtherPSYCHOLOGIST LICENSE