Provider Demographics
NPI:1760930911
Name:MALLOY, ROXANNE
Entity Type:Individual
Prefix:
First Name:ROXANNE
Middle Name:
Last Name:MALLOY
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 1:110 COLUMBIA STREET
Mailing Address - Street 2:1ST FLOOR SOUTH
Mailing Address - City:ADAMS
Mailing Address - State:MA
Mailing Address - Zip Code:01220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 COLUMBIA STREET
Practice Address - Street 2:1ST FLOOR SOUTH
Practice Address - City:ADAMS
Practice Address - State:MA
Practice Address - Zip Code:01220
Practice Address - Country:US
Practice Address - Phone:413-684-8619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-16
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA-01220-9723103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst