Provider Demographics
NPI:1538557749
Name:BAILEY, MALLORY (MA)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:BAILEY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 TY BLUFF RD
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-3447
Mailing Address - Country:US
Mailing Address - Phone:704-736-5161
Mailing Address - Fax:
Practice Address - Street 1:137 LAXTON RD STE 3B
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-3144
Practice Address - Country:US
Practice Address - Phone:434-278-0215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-23
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701008393101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health