Provider Demographics
NPI:1770002628
Name:FELT, MALLORY ANN (LICSW)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:ANN
Last Name:FELT
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11749 COUNTRYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:PARKERS PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:56361-4532
Mailing Address - Country:US
Mailing Address - Phone:320-314-2032
Mailing Address - Fax:
Practice Address - Street 1:507 22ND AVE E STE 1
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-5186
Practice Address - Country:US
Practice Address - Phone:320-762-5124
Practice Address - Fax:320-762-2422
Is Sole Proprietor?:No
Enumeration Date:2017-09-12
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN237961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical