Provider Demographics
NPI:1841749611
Name:GRANT, MALLORY (MED, LPC)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16055 PERRY HWY
Mailing Address - Street 2:BUILDING 3
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-6821
Mailing Address - Country:US
Mailing Address - Phone:724-502-2162
Mailing Address - Fax:724-443-8939
Practice Address - Street 1:16055 PERRY HWY
Practice Address - Street 2:BUILDING 3
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-6821
Practice Address - Country:US
Practice Address - Phone:724-502-2162
Practice Address - Fax:724-443-8939
Is Sole Proprietor?:No
Enumeration Date:2016-09-22
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC008986101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional