Healthcare Provider Details

I. General information

NPI: 1861634057
Provider Name (Legal Business Name): LAURA MARIE MALLOY LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2009
Last Update Date: 04/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 MERRIMAC ST 4TH FLOOR
BOSTON MA
02114-4714
US

IV. Provider business mailing address

7 UNION ST # 3
BEVERLY MA
01915-5101
US

V. Phone/Fax

Practice location:
  • Phone: 617-643-6090
  • Fax: 617-643-6077
Mailing address:
  • Phone: 978-821-4784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1027813
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: