Provider Demographics
NPI:1841884277
Name:MALLIN, MATTHEW (LCSW)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MALLIN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 CHEROKEE LN
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-3006
Mailing Address - Country:US
Mailing Address - Phone:608-322-8553
Mailing Address - Fax:
Practice Address - Street 1:1520 MADISON AVE
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-3100
Practice Address - Country:US
Practice Address - Phone:920-563-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-25
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7548-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical