Healthcare Provider Details

I. General information

NPI: 1730723495
Provider Name (Legal Business Name): MALLORY HASENAUER CDCA. 173136
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2019
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 MARION PIKE STE 3
COAL GROVE OH
45638-2958
US

IV. Provider business mailing address

323 MARION PIKE STE 3
COAL GROVE OH
45638-2958
US

V. Phone/Fax

Practice location:
  • Phone: 740-646-6640
  • Fax: 866-475-7263
Mailing address:
  • Phone: 304-544-8103
  • Fax: 866-475-7263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.173136
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPS.003696
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: