Provider Demographics
NPI:1467346684
Name:MOORE, MALLORY MARSHALL (LSW)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:MARSHALL
Last Name:MOORE
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 1:2402 LOMBARD ST UNIT 2
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-1023
Mailing Address - Country:US
Mailing Address - Phone:202-834-7312
Mailing Address - Fax:
Practice Address - Street 1:123 CHESTNUT ST STE 304
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-3059
Practice Address - Country:US
Practice Address - Phone:215-399-4128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-03
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW1427891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical