Provider Demographics
NPI:1376977330
Name:DERRICK, MALLORY (BA)
Entity Type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:
Last Name:DERRICK
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2410 CHARLOTTE AVE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1517
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2410 CHARLOTTE AVE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1517
Practice Address - Country:US
Practice Address - Phone:615-321-2575
Practice Address - Fax:615-327-4536
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-27
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical