Provider Demographics
NPI:1518128131
Name:MALLORY, KATHERINE OLIVIA (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:OLIVIA
Last Name:MALLORY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 CHURCH ST STE 4
Mailing Address - Street 2:
Mailing Address - City:LENOX
Mailing Address - State:MA
Mailing Address - Zip Code:01240-2503
Mailing Address - Country:US
Mailing Address - Phone:413-551-2251
Mailing Address - Fax:
Practice Address - Street 1:4545 42ND ST NW
Practice Address - Street 2:SUITE 310
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20016
Practice Address - Country:US
Practice Address - Phone:917-833-6411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-17
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2614592084P0804X
DCMD0402192084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry