Provider Demographics
NPI:1780022194
Name:MALLIS, GREGORY V (PSYD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:V
Last Name:MALLIS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1870 LEONARD STREET SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-5650
Mailing Address - Country:US
Mailing Address - Phone:616-956-1122
Mailing Address - Fax:616-956-8033
Practice Address - Street 1:1870 LEONARD ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-5650
Practice Address - Country:US
Practice Address - Phone:616-956-1122
Practice Address - Fax:616-956-8033
Is Sole Proprietor?:No
Enumeration Date:2013-06-07
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015440103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist