Healthcare Provider Details

I. General information

NPI: 1356994792
Provider Name (Legal Business Name): ERICA MALLOY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2019
Last Update Date: 10/25/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5151 MOCHEL DR
DOWNERS GROVE IL
60515-5076
US

IV. Provider business mailing address

1562 OREGON TRL
ELK GROVE VILLAGE IL
60007-2852
US

V. Phone/Fax

Practice location:
  • Phone: 847-494-1820
  • Fax:
Mailing address:
  • Phone: 847-494-1820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.027652
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: