Provider Demographics
NPI:1831804855
Name:SUNSTROM, MALLORY
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:SUNSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 BEDFORD AVE
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33403-1122
Mailing Address - Country:US
Mailing Address - Phone:404-486-3112
Mailing Address - Fax:
Practice Address - Street 1:3450 NORTHLAKE BLVD STE 208
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33403-1712
Practice Address - Country:US
Practice Address - Phone:404-486-3112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW194361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical