Provider Demographics
NPI:1811304660
Name:SEIDMAN, MALLORY (PSYD)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:SEIDMAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 INNESS PL
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-4923
Mailing Address - Country:US
Mailing Address - Phone:917-426-7158
Mailing Address - Fax:
Practice Address - Street 1:16 INNESS PL
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-4923
Practice Address - Country:US
Practice Address - Phone:917-426-7158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-14
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00571000103G00000X, 103TC0700X
NY021231103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical