Healthcare Provider Details

I. General information

NPI: 1033582127
Provider Name (Legal Business Name): OLIVIA CASSIDY MALLOCH CADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2015
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 MANOR PKWY STE 201
SALEM NH
03079-2841
US

IV. Provider business mailing address

74 DOWD RD
BANGOR ME
04401-6700
US

V. Phone/Fax

Practice location:
  • Phone: 603-757-5643
  • Fax:
Mailing address:
  • Phone: 207-947-6800
  • Fax: 207-947-6872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLC6169
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: