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General NPI Number Information
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NPI Number | 1477185098
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Entity Type | Individual
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Provider Name | SHANITA MALLORY LPC
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Gender | Female
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Dates
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Enumeration Date | 02/11/2020
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Last Update Date | 03/30/2023
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Provider Practice Location Address
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Address Line | 900 COMMONWEALTH PL STE 225
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City | VIRGINIA BEACH
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State | VA
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Zip | 23464-4517
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Country | US
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Telephone | 757-895-7007
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Fax |
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Provider Business Mailing Address
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Address Line | 10 BIG BETHEL RD APT A
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City | HAMPTON
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State | VA
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Zip | 23666-4736
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Country | US
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Telephone | 757-589-8720
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 0704007981
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License Number State | VA
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