Provider Demographics
NPI:1679831549
Name:SAMPLE, MALLORY C (MSW, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:C
Last Name:SAMPLE
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5609 DEVONSHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-2872
Mailing Address - Country:US
Mailing Address - Phone:314-494-1714
Mailing Address - Fax:
Practice Address - Street 1:4485 WESTMINSTER PL
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-1812
Practice Address - Country:US
Practice Address - Phone:314-535-7911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-30
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20120074471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical