Provider Demographics
NPI:1609324334
Name:MALLON, SUSANNAH
Entity Type:Individual
Prefix:
First Name:SUSANNAH
Middle Name:
Last Name:MALLON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CROZIER AVE
Mailing Address - Street 2:
Mailing Address - City:NATIONAL PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08063-1512
Mailing Address - Country:US
Mailing Address - Phone:856-693-4192
Mailing Address - Fax:
Practice Address - Street 1:36 KRESSON RD
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-3227
Practice Address - Country:US
Practice Address - Phone:856-693-4192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-11
Last Update Date:2016-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC056272001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical