Provider Demographics
NPI:1154964500
Name:MALLES, ANNA CATHERINE (LCSWA)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:CATHERINE
Last Name:MALLES
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 EAST BLVD APT 2
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-4813
Mailing Address - Country:US
Mailing Address - Phone:407-670-9374
Mailing Address - Fax:
Practice Address - Street 1:415 E 4TH ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-2405
Practice Address - Country:US
Practice Address - Phone:980-402-7526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-17
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP013820101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health