Provider Demographics
NPI:1730723495
Name:HASENAUER, MALLORY (CDCA 173136)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:HASENAUER
Suffix:
Gender:F
Credentials:CDCA 173136
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 MARION PIKE STE 3
Mailing Address - Street 2:
Mailing Address - City:COAL GROVE
Mailing Address - State:OH
Mailing Address - Zip Code:45638-2958
Mailing Address - Country:US
Mailing Address - Phone:304-544-8103
Mailing Address - Fax:866-475-7263
Practice Address - Street 1:323 MARION PIKE STE 3
Practice Address - Street 2:
Practice Address - City:COAL GROVE
Practice Address - State:OH
Practice Address - Zip Code:45638-2958
Practice Address - Country:US
Practice Address - Phone:740-646-6640
Practice Address - Fax:866-475-7263
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.173136101YA0400X
171M00000X
OHAPS.003696175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator