Provider Demographics
NPI:1568947307
Name:MALLORY, ANGELA MONIQUE (CDCA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MONIQUE
Last Name:MALLORY
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5277 HEDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43229-4429
Mailing Address - Country:US
Mailing Address - Phone:614-902-5615
Mailing Address - Fax:
Practice Address - Street 1:5277 HEDGEWOOD RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43229-4429
Practice Address - Country:US
Practice Address - Phone:614-902-5615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH166863101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty