Healthcare Provider Details

I. General information

NPI: 1053140442
Provider Name (Legal Business Name): MADELEINE MALLON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MADELEINE DELORIA-MANCINI LMSW

II. Dates (important events)

Enumeration Date: 08/01/2024
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

257 MAIN ST
BINGHAMTON NY
13905-2522
US

IV. Provider business mailing address

165 MAIN ST STE A
CORTLAND NY
13045-3191
US

V. Phone/Fax

Practice location:
  • Phone: 607-729-6206
  • Fax:
Mailing address:
  • Phone: 607-753-0234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number110433
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: