Provider Demographics
NPI:1639406614
Name:MALLORY, KEENAN ANE (LCSW)
Entity Type:Individual
Prefix:
First Name:KEENAN
Middle Name:ANE
Last Name:MALLORY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2571 STRATFORD POINTE DR
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-8058
Mailing Address - Country:US
Mailing Address - Phone:321-514-5048
Mailing Address - Fax:
Practice Address - Street 1:1900 S HARBOR CITY BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-4749
Practice Address - Country:US
Practice Address - Phone:321-514-5048
Practice Address - Fax:321-610-8880
Is Sole Proprietor?:No
Enumeration Date:2009-11-11
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL92661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9266OtherLCSW