Healthcare Provider Details

I. General information

NPI: 1023964160
Provider Name (Legal Business Name): DEIDRE MALLON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2026
Last Update Date: 03/10/2026
Certification Date: 03/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 UPTOWN BLVD NE
ALBUQUERQUE NM
87110-4202
US

IV. Provider business mailing address

PO BOX 25704
ALBUQUERQUE NM
87125-0704
US

V. Phone/Fax

Practice location:
  • Phone: 505-855-9804
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number402427
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: