Provider Demographics
NPI:1942559307
Name:DIMLER, MALLORY (PHD)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:DIMLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 MILL ST
Mailing Address - Street 2:MCLEAN HOSPITAL
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 MILL ST.
Practice Address - Street 2:MCLEAN HOSPITAL
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478
Practice Address - Country:US
Practice Address - Phone:617-855-3618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-31
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9958103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265EMedicaid