MEDICARE: MALLORY WILLIAMS LMSW LSSW

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	10537	TN
2	1041S0200X	School Social Worker	000634883	TN

General Provider Information

NPI Number	:	1750732855
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MALLORY WILLIAMS LMSW LSSW

Provider Business Mailing Address
First Line	:	7229 STONE GARDEN DR
Second Line	:
City	:	OLIVE BRANCH
State	:	MS
Zip	:	38654-6419
Country	:	US
Telephone Number	:	870-692-8102
Fax Number	:

Provider Business Practice Location Address
First Line	:	7229 STONE GARDEN DR
Second Line	:
City	:	OLIVE BRANCH
State	:	MS
Zip	:	38654-6419
Country	:	US
Telephone Number	:	870-692-8102
Fax Number	:

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

Provider Enumeration Date	:	06/29/2016
Last Update Date	:	06/29/2016

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