Provider Demographics
NPI:1912392143
Name:DANGELO, MALLORY ANNE (DO)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:ANNE
Last Name:DANGELO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:ANNE
Other - Last Name:KOLICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:5655 HUDSON DR STE 305
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236-4454
Mailing Address - Country:US
Mailing Address - Phone:330-650-2111
Mailing Address - Fax:330-650-2211
Practice Address - Street 1:5655 HUDSON DR STE 305
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:OH
Practice Address - Zip Code:44236-4454
Practice Address - Country:US
Practice Address - Phone:330-650-2111
Practice Address - Fax:330-650-2211
Is Sole Proprietor?:No
Enumeration Date:2015-04-03
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.0124882084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry