Healthcare Provider Details

I. General information

NPI: 1437061215
Provider Name (Legal Business Name): MALLORY ANN MANAHAN MSW, ASW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 E FLORIDA AVE
HEMET CA
92543-4512
US

IV. Provider business mailing address

PO BOX 7173
RIVERSIDE CA
92513-7173
US

V. Phone/Fax

Practice location:
  • Phone: 951-312-4476
  • Fax:
Mailing address:
  • Phone: 951-312-4476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW139394
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: