Provider Demographics
NPI:1437789104
Name:BUSHEY, MALLORY (LICSW)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:BUSHEY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:640 JACKSON ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2502
Practice Address - Country:US
Practice Address - Phone:651-254-3448
Practice Address - Fax:651-254-3470
Is Sole Proprietor?:No
Enumeration Date:2020-01-22
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN22308104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker