Provider Demographics
NPI:1548966831
Name:NICKLAS, MALLORY LYNN (LSW)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:LYNN
Last Name:NICKLAS
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 1:1585 S JASMINE ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80224-1928
Mailing Address - Country:US
Mailing Address - Phone:303-249-8888
Mailing Address - Fax:
Practice Address - Street 1:1705 OUTTER MARKER RD
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80108-9332
Practice Address - Country:US
Practice Address - Phone:303-249-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-07
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00099234101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical