Healthcare Provider Details

I. General information

NPI: 1578327904
Provider Name (Legal Business Name): MALLORY JEANNE CAUDILL LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2024
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1481 W 10TH ST
INDIANAPOLIS IN
46202-2803
US

IV. Provider business mailing address

777 N MERIDIAN ST
INDIANAPOLIS IN
46204-1420
US

V. Phone/Fax

Practice location:
  • Phone: 317-910-5532
  • Fax:
Mailing address:
  • Phone: 317-508-9444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number33011681A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: