Healthcare Provider Details

I. General information

NPI: 1235044553
Provider Name (Legal Business Name): MALLORY LACOMIS MSCCCSLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1548 SANS SOUCI PKWY
HANOVER TOWNSHIP PA
18706-6028
US

IV. Provider business mailing address

1548 SANS SOUCI PKWY
HANOVER TOWNSHIP PA
18706-6028
US

V. Phone/Fax

Practice location:
  • Phone: 570-825-8725
  • Fax: 570-822-3735
Mailing address:
  • Phone: 570-825-8725
  • Fax: 570-822-3735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSL011350
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: