Provider Demographics
NPI:1700411253
Name:MALLEY, MARYBETH ANN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARYBETH
Middle Name:ANN
Last Name:MALLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARYBETH
Other - Middle Name:ANN
Other - Last Name:UNDERWOOD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:714 SW 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33435-6738
Mailing Address - Country:US
Mailing Address - Phone:772-285-2147
Mailing Address - Fax:
Practice Address - Street 1:1375 GATEWAY BLVD
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-8304
Practice Address - Country:US
Practice Address - Phone:561-314-5074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-05
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW130161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical