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General NPI Number Information
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NPI Number | 1780319525
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Entity Type | Individual
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Provider Name | MALLORY TEDRICK LISW
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Gender | Female
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Dates
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Enumeration Date | 07/17/2022
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Last Update Date | 03/03/2025
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Provider Practice Location Address
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Address Line | 20525 DETROIT RD STE 9
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City | ROCKY RIVER
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State | OH
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Zip | 44116-2444
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Country | US
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Telephone | 440-782-1117
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Fax |
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Provider Business Mailing Address
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Address Line | 20400 LAKE RD
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City | ROCKY RIVER
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State | OH
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Zip | 44116-1330
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Country | US
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Telephone | 440-728-7590
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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 | 104100000X
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Taxonomy Name | Social Worker
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License Number | S.1700101
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | I.2506260
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License Number State | OH
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