Healthcare Provider Details

I. General information

NPI: 1407947989
Provider Name (Legal Business Name): ANNETTE S MALLEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANNETTE S LEMIEUX-ST.GEORGE

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 MYSTIC AVE
MEDFORD MA
02155-4632
US

IV. Provider business mailing address

5 HIGH ST
SOUTH DARTMOUTH MA
02748-3808
US

V. Phone/Fax

Practice location:
  • Phone: 781-396-1199
  • Fax: 781-396-1439
Mailing address:
  • Phone: 508-942-1103
  • Fax: 781-396-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number207323
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: