Provider Demographics
NPI:1639354723
Name:MALLOCH, CYNTHIA JOAN (LLPC)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:JOAN
Last Name:MALLOCH
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N WEST AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202
Mailing Address - Country:US
Mailing Address - Phone:517-780-3336
Mailing Address - Fax:517-796-4561
Practice Address - Street 1:1200 N WEST AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202
Practice Address - Country:US
Practice Address - Phone:517-789-5581
Practice Address - Fax:517-796-4561
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010523101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional