Provider Demographics
NPI:1467239087
Name:QUALLS, MARY L (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:QUALLS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LUCY
Other - Middle Name:
Other - Last Name:QUALLS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:12730 W AVALON DR
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-6645
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:501 E PLAZA CIR STE 13
Practice Address - Street 2:
Practice Address - City:LITCHFIELD PARK
Practice Address - State:AZ
Practice Address - Zip Code:85340-4909
Practice Address - Country:US
Practice Address - Phone:602-818-2615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-08
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-13257101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health