Provider Demographics
NPI:1700961695
Name:MALLERY, BRENDA W (LCSW)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:W
Last Name:MALLERY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2114 BAYBERRY ST
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-1402
Mailing Address - Country:US
Mailing Address - Phone:757-450-7587
Mailing Address - Fax:
Practice Address - Street 1:2940 N LYNNHAVEN RD
Practice Address - Street 2:SUITE 110
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-6949
Practice Address - Country:US
Practice Address - Phone:757-450-7587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040011131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1861562472Medicaid
R86613Medicare UPIN
VA1861562472Medicaid