=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225848864
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MALLORY CLAIRE VISSER-PARDEE LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2025
-----------------------------------------------------
Last Update Date | 03/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1521 MERRILL DRIVE SUITE D220
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72211-1654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-660-6893
-----------------------------------------------------
Fax | 501-954-7798
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 251970
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72225-1970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-666-8686
-----------------------------------------------------
Fax | 501-660-6830
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 9456-C
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------