Provider Demographics
NPI:1598461378
Name:WILLISTON, MALLORY M (BA)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:M
Last Name:WILLISTON
Suffix:
Gender:F
Credentials:BA
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 120
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-0120
Mailing Address - Country:US
Mailing Address - Phone:860-437-4550
Mailing Address - Fax:860-661-4262
Practice Address - Street 1:38 S BROAD ST
Practice Address - Street 2:
Practice Address - City:PAWCATUCK
Practice Address - State:CT
Practice Address - Zip Code:06379-3966
Practice Address - Country:US
Practice Address - Phone:860-437-4550
Practice Address - Fax:860-661-4262
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-03
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional