Provider Demographics
NPI:1508966417
Name:MALLACH, DIANE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:MALLACH
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:PO BOX 71
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040
Mailing Address - Country:US
Mailing Address - Phone:201-787-7142
Mailing Address - Fax:973-450-0162
Practice Address - Street 1:50 NEWARK AVE
Practice Address - Street 2:#306
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109
Practice Address - Country:US
Practice Address - Phone:973-450-0220
Practice Address - Fax:973-450-0162
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC002842001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
7081448OtherAETNA
P3470927OtherOXFORD
7081448OtherAETNA