Healthcare Provider Details

I. General information

NPI: 1508925884
Provider Name (Legal Business Name): WILLIAM SMITH MALLOY JR. MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 10/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 WEST U.S. 2
WAKEFIELD MI
49968
US

IV. Provider business mailing address

PO BOX 422
IRONWOOD MI
49938-0422
US

V. Phone/Fax

Practice location:
  • Phone: 906-229-6120
  • Fax:
Mailing address:
  • Phone: 906-932-2641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801015913
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: