Healthcare Provider Details

I. General information

NPI: 1881245298
Provider Name (Legal Business Name): MALLORY HALLSTEAD LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2019
Last Update Date: 08/08/2025
Certification Date: 08/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 BROADWAY BLVD SE
ALBUQUERQUE NM
87102-3425
US

IV. Provider business mailing address

391 WESTERN AVE
ALBANY NY
12203-1401
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-6988
  • Fax: 505-242-6972
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSWB-2023-0850
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: