Provider Demographics
NPI:1043257272
Name:MALLERY, SALLY (LMHC)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:MALLERY
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 SUNSET RD
Mailing Address - Street 2:F5
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34689-2767
Mailing Address - Country:US
Mailing Address - Phone:727-943-8600
Mailing Address - Fax:
Practice Address - Street 1:5315 TROUBLE CREEK RD
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-4949
Practice Address - Country:US
Practice Address - Phone:727-849-5588
Practice Address - Fax:727-849-5527
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH1962101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health