Provider Demographics
NPI:1558887604
Name:MOSHER, MALLORY KATHLEEN (LISW, LICDC)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:KATHLEEN
Last Name:MOSHER
Suffix:
Gender:F
Credentials:LISW, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 E GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44304-1137
Mailing Address - Country:US
Mailing Address - Phone:330-669-2222
Mailing Address - Fax:
Practice Address - Street 1:49 E GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44304-1137
Practice Address - Country:US
Practice Address - Phone:330-996-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-21
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.162136101YA0400X
OHI.23044441041C0700X
OH164031101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical