Provider Demographics
NPI:1336449776
Name:MALLOY, VENUS DANIELLE (MS, NCC, LPCA)
Entity Type:Individual
Prefix:MS
First Name:VENUS
Middle Name:DANIELLE
Last Name:MALLOY
Suffix:
Gender:F
Credentials:MS, NCC, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910B WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-4090
Mailing Address - Country:US
Mailing Address - Phone:336-253-0037
Mailing Address - Fax:
Practice Address - Street 1:2817 REILLY RD STOP A
Practice Address - Street 2:MCXC ASAP
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28310-7301
Practice Address - Country:US
Practice Address - Phone:910-907-9666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC203136101Y00000X
NCA8214101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor