Provider Demographics
NPI:1518719855
Name:COLEGROVE, MALLORY MARIE
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:MARIE
Last Name:COLEGROVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:MARIE
Other - Last Name:DUSSAULT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:152 MAGGIE WAY
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-1905
Mailing Address - Country:US
Mailing Address - Phone:630-987-9342
Mailing Address - Fax:
Practice Address - Street 1:152 MAGGIE WAY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-1905
Practice Address - Country:US
Practice Address - Phone:630-987-9342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health