Provider Demographics
NPI:1356994792
Name:MALLOY, ERICA
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:MALLOY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1562 OREGON TRL
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-2852
Mailing Address - Country:US
Mailing Address - Phone:847-494-1820
Mailing Address - Fax:
Practice Address - Street 1:5151 MOCHEL DR
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-5076
Practice Address - Country:US
Practice Address - Phone:847-494-1820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-23
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041S0200X
IL149.0276521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool