Provider Demographics
NPI:1477185098
Name:MALLORY, SHANITA (LPC)
Entity type:Individual
Prefix:
First Name:SHANITA
Middle Name:
Last Name:MALLORY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 BIG BETHEL RD APT A
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-4736
Mailing Address - Country:US
Mailing Address - Phone:757-589-8720
Mailing Address - Fax:
Practice Address - Street 1:900 COMMONWEALTH PL STE 225
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-4517
Practice Address - Country:US
Practice Address - Phone:757-895-7007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-11
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704007981101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty