Provider Demographics
NPI:1447716246
Name:UNDERWOOD, MALLIE DANIELLE (LCSW)
Entity type:Individual
Prefix:
First Name:MALLIE
Middle Name:DANIELLE
Last Name:UNDERWOOD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 W BEN WHITE BLVD STE 210A
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-7182
Mailing Address - Country:US
Mailing Address - Phone:512-960-4533
Mailing Address - Fax:512-703-1394
Practice Address - Street 1:1221 W BEN WHITE BLVD
Practice Address - Street 2:STE 210A
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-7182
Practice Address - Country:US
Practice Address - Phone:512-472-4357
Practice Address - Fax:512-703-1394
Is Sole Proprietor?:No
Enumeration Date:2019-02-17
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX593231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical