Healthcare Provider Details

I. General information

NPI: 1174120687
Provider Name (Legal Business Name): MALLORY HEMERLEIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2020
Last Update Date: 10/03/2025
Certification Date: 10/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 4TH ST NW STE E2
LOS RANCHOS NM
87107-5800
US

IV. Provider business mailing address

1808 MANN ST APT B
SANTA FE NM
87505-3430
US

V. Phone/Fax

Practice location:
  • Phone: 505-456-0619
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberM-11344
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: