Provider Demographics
NPI:1205445145
Name:DAVIS, MALLORIE E (LSW)
Entity type:Individual
Prefix:
First Name:MALLORIE
Middle Name:E
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 W 5TH AVE STE 112
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-2907
Mailing Address - Country:US
Mailing Address - Phone:614-233-1062
Mailing Address - Fax:
Practice Address - Street 1:1350 W 5TH AVE STE 112
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-2907
Practice Address - Country:US
Practice Address - Phone:614-233-1062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.20046851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty