Provider Demographics
NPI:1205094554
Name:MALLOY, VICTORIA (LCPC)
Entity type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:
Last Name:MALLOY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:183 E BETHEL DR
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-1456
Mailing Address - Country:US
Mailing Address - Phone:815-939-1900
Mailing Address - Fax:815-939-1902
Practice Address - Street 1:183 E BETHEL DR
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-1456
Practice Address - Country:US
Practice Address - Phone:815-939-1900
Practice Address - Fax:815-939-1902
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-22
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-006914101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional