Healthcare Provider Details

I. General information

NPI: 1548835226
Provider Name (Legal Business Name): SAMANTHA MALLONI LCDCIII
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2021
Last Update Date: 04/29/2024
Certification Date: 04/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 MAY DR
HARRISON OH
45030-2024
US

IV. Provider business mailing address

3621 ROSSGATE CT
HAMILTON OH
45013-9558
US

V. Phone/Fax

Practice location:
  • Phone: 513-738-7600
  • Fax: 513-738-7601
Mailing address:
  • Phone: 513-738-7600
  • Fax: 513-738-7601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.176222
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDCIII.162371
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: