Provider Demographics
NPI:1851983274
Name:STANLEY, MALLORIE TAYLOR (LICSW)
Entity Type:Individual
Prefix:MS
First Name:MALLORIE
Middle Name:TAYLOR
Last Name:STANLEY
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 1:149 HANOVER ST STE 200
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03101-2245
Mailing Address - Country:US
Mailing Address - Phone:603-696-4872
Mailing Address - Fax:
Practice Address - Street 1:149 HANOVER ST STE 200
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03101-2245
Practice Address - Country:US
Practice Address - Phone:603-696-4872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-08
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12111273-3502104100000X
UT12111273-35011041C0700X
NH30001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker