Provider Demographics
NPI:1366868648
Name:MALLARD, ALEXANDRA
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:MALLARD
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 1:360 MASSACHUSETTS AVE.
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:360 MASSACHUSETTS AVE.
Practice Address - Street 2:SUITE 201
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720
Practice Address - Country:US
Practice Address - Phone:978-263-3427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-11
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health