Healthcare Provider Details

I. General information

NPI: 1174345854
Provider Name (Legal Business Name): MRS. MALLORY MARRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2024
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 SOTHEL AVE
CHARLESTON SC
29407-7320
US

IV. Provider business mailing address

18 SOTHEL AVE
CHARLESTON SC
29407-7320
US

V. Phone/Fax

Practice location:
  • Phone: 443-562-8242
  • Fax:
Mailing address:
  • Phone: 443-562-8242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC15341
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC019497
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number9722
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPRC200012642
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: