Provider Demographics
NPI:1821585290
Name:MALLORY, ANDREA (LISW)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:MALLORY
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E MCMILLAN ST
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-1922
Mailing Address - Country:US
Mailing Address - Phone:513-221-3350
Mailing Address - Fax:
Practice Address - Street 1:7630 BETHANY RD
Practice Address - Street 2:
Practice Address - City:LIBERTY TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:45044-9583
Practice Address - Country:US
Practice Address - Phone:513-588-7700
Practice Address - Fax:513-759-2024
Is Sole Proprietor?:No
Enumeration Date:2018-04-20
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.19019631041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker