MEDICARE: MALLORY WILSON

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	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1982308599
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MALLORY WILSON

Provider Business Mailing Address
First Line	:	516 BEACHCLIFF ROW DR
Second Line	:
City	:	ROCKY RIVER
State	:	OH
Zip	:	44116-1800
Country	:	US
Telephone Number	:	440-840-2252
Fax Number	:

Provider Business Practice Location Address
First Line	:	4401 W 150TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44135-1311
Country	:	US
Telephone Number	:	440-840-2252
Fax Number	:

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

Provider Enumeration Date	:	03/28/2023
Last Update Date	:	03/28/2023

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Directions to “ MALLORY WILSON ” Practice Location

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