Provider Demographics
NPI:1750732855
Name:WILLIAMS, MALLORY (LMSW LSSW)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LMSW LSSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7229 STONE GARDEN DR
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-6419
Mailing Address - Country:US
Mailing Address - Phone:870-692-8102
Mailing Address - Fax:
Practice Address - Street 1:7229 STONE GARDEN DR
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-6419
Practice Address - Country:US
Practice Address - Phone:870-692-8102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-29
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10537104100000X
TN0006348831041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool