Provider Demographics
NPI:1467747808
Name:MALLORY, REGINA MALLORY (LCSW)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:MALLORY
Last Name:MALLORY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 STILLWATER LOOP
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MT
Mailing Address - Zip Code:59019-7326
Mailing Address - Country:US
Mailing Address - Phone:913-558-7638
Mailing Address - Fax:
Practice Address - Street 1:142 STILLWATER LOOP
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MT
Practice Address - Zip Code:59019-7326
Practice Address - Country:US
Practice Address - Phone:913-558-7638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT989-LCSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical