Provider Demographics
NPI:1326640426
Name:MATTIE, MALLORY (LMSW)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:MATTIE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 CHOCTAW RDG S
Mailing Address - Street 2:
Mailing Address - City:DAHLONEGA
Mailing Address - State:GA
Mailing Address - Zip Code:30533-5627
Mailing Address - Country:US
Mailing Address - Phone:678-231-3901
Mailing Address - Fax:
Practice Address - Street 1:1435 HAW CREEK CIR
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-6566
Practice Address - Country:US
Practice Address - Phone:470-253-1963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW009614104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker