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General NPI Number Information
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NPI Number | 1225078710
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Entity Type | Individual
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Provider Name | LYNETTE L MALLOCH PHD
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Gender | Female
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Dates
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Enumeration Date | 06/07/2006
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Last Update Date | 02/13/2019
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Provider Practice Location Address
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Address Line | 14300 GALLANT FOX LN STE 107
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City | BOWIE
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State | MD
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Zip | 20715-4031
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Country | US
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Telephone | 410-562-6109
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Fax |
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Provider Business Mailing Address
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Address Line | 181 S SOUTHWOOD AVE
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City | ANNAPOLIS
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State | MD
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Zip | 21401-4025
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Country | US
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Telephone | 410-562-6109
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 01817
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License Number State | MD
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