MEDICARE: MS. LAVONNE MALLORY AA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041S0200X	School Social Worker

General Provider Information

NPI Number	:	1255532966
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LAVONNE MALLORY AA

Provider Business Mailing Address
First Line	:	822 9TH ST
Second Line	:
City	:	RICHMOND
State	:	CA
Zip	:	94801-2233
Country	:	US
Telephone Number	:	510-231-7573
Fax Number	:	510-307-4461

Provider Business Practice Location Address
First Line	:	3029 MACDONALD AVE
Second Line	:
City	:	RICHMOND
State	:	CA
Zip	:	94804-3010
Country	:	US
Telephone Number	:	510-231-7573
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/30/2007
Last Update Date	:	07/08/2007

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