MEDICARE: MALLORY KIERNAN APSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	130860	WI

General Provider Information

NPI Number	:	1073027538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MALLORY KIERNAN APSW

Provider Business Mailing Address
First Line	:	17 S RIVER ST STE 254
Second Line	:
City	:	JANESVILLE
State	:	WI
Zip	:	53548-3863
Country	:	US
Telephone Number	:	608-755-5260
Fax Number	:	608-755-5267

Provider Business Practice Location Address
First Line	:	778 LOIS DR
Second Line	:
City	:	SUN PRAIRIE
State	:	WI
Zip	:	53590-1100
Country	:	US
Telephone Number	:	608-755-5260
Fax Number	:	608-755-5267

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/20/2017
Last Update Date	:	11/20/2017

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Directions to “ MALLORY KIERNAN APSW” Practice Location

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