Provider Demographics
NPI:1255532966
Name:MALLORY, LAVONNE (AA)
Entity type:Individual
Prefix:MS
First Name:LAVONNE
Middle Name:
Last Name:MALLORY
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:822 9TH ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94801-2233
Mailing Address - Country:US
Mailing Address - Phone:510-231-7573
Mailing Address - Fax:510-307-4461
Practice Address - Street 1:3029 MACDONALD AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94804-3010
Practice Address - Country:US
Practice Address - Phone:510-231-7573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool