Provider Demographics
NPI:1497599047
Name:CHARLAND, MALLORY DIANA (LICSW)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:DIANA
Last Name:CHARLAND
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 SUSIE WILSON RD UNIT 111
Mailing Address - Street 2:
Mailing Address - City:ESSEX JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05452-2856
Mailing Address - Country:US
Mailing Address - Phone:028-922-7672
Mailing Address - Fax:
Practice Address - Street 1:42 SUSIE WILSON RD UNIT 111
Practice Address - Street 2:
Practice Address - City:ESSEX JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05452-2856
Practice Address - Country:US
Practice Address - Phone:802-404-2185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-19
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089.01359171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical