Provider Demographics
NPI:1376275651
Name:MICHAEL, MALLORY
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:MICHAEL
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 1:740 LONG VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:GARDNERVILLE
Mailing Address - State:NV
Mailing Address - Zip Code:89460-8138
Mailing Address - Country:US
Mailing Address - Phone:775-741-0359
Mailing Address - Fax:
Practice Address - Street 1:975 KIRMAN AVE
Practice Address - Street 2:CH124
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502
Practice Address - Country:US
Practice Address - Phone:775-419-4899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV10086-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical