Provider Demographics
NPI:1780319525
Name:TEDRICK, MALLORY (LISW)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:TEDRICK
Suffix:
Gender:
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20400 LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY RIVER
Mailing Address - State:OH
Mailing Address - Zip Code:44116-1330
Mailing Address - Country:US
Mailing Address - Phone:440-728-7590
Mailing Address - Fax:
Practice Address - Street 1:20525 DETROIT RD STE 9
Practice Address - Street 2:
Practice Address - City:ROCKY RIVER
Practice Address - State:OH
Practice Address - Zip Code:44116-2444
Practice Address - Country:US
Practice Address - Phone:440-782-1117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-17
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1700101104100000X
OHI.25062601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker