MEDICARE: EBONY MALLARD LPC

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	101YP2500X	Professional Counselor	LPC006830	GA

General Provider Information

NPI Number	:	1942560412
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EBONY MALLARD LPC

Provider Business Mailing Address
First Line	:	2609 WATERDALE RD SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-8125
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2801 BUFORD HWY NE STE 501
Second Line	:
City	:	BROOKHAVEN
State	:	GA
Zip	:	30329-2137
Country	:	US
Telephone Number	:	404-491-0377
Fax Number	:

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

Provider Enumeration Date	:	05/18/2012
Last Update Date	:	03/11/2025

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