Provider Demographics
NPI:1780066084
Name:MALLORY, NICHOLE (LCSW)
Entity type:Individual
Prefix:MS
First Name:NICHOLE
Middle Name:
Last Name:MALLORY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:
Other - Last Name:SERJE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:319 CHARTER RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-1208
Mailing Address - Country:US
Mailing Address - Phone:860-967-6661
Mailing Address - Fax:
Practice Address - Street 1:43 WOODLAND ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-2363
Practice Address - Country:US
Practice Address - Phone:860-241-0317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-23
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical