Provider Demographics
NPI:1841414349
Name:WARD, MALLORY (BA, CAC)
Entity type:Individual
Prefix:MS
First Name:MALLORY
Middle Name:
Last Name:WARD
Suffix:
Gender:F
Credentials:BA, CAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:562 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-3721
Mailing Address - Country:US
Mailing Address - Phone:570-552-3713
Mailing Address - Fax:
Practice Address - Street 1:562 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-3721
Practice Address - Country:US
Practice Address - Phone:570-552-3713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder