Provider Demographics
NPI:1861876211
Name:DEVONA, MALLORY ROSE (MS, NCC, LPC)
Entity type:Individual
Prefix:MS
First Name:MALLORY
Middle Name:ROSE
Last Name:DEVONA
Suffix:
Gender:F
Credentials:MS, NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 LEARY DR
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-3707
Mailing Address - Country:US
Mailing Address - Phone:860-857-4769
Mailing Address - Fax:
Practice Address - Street 1:2 LEARY DR
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385
Practice Address - Country:US
Practice Address - Phone:860-857-4769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-15
Last Update Date:2018-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2789101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008060321Medicaid