Provider Demographics
NPI:1194549683
Name:MALLENBAUM, IRENE MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:MARIE
Last Name:MALLENBAUM
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 1:1908 WESTHAM WOODS PL
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-6330
Mailing Address - Country:US
Mailing Address - Phone:757-769-3764
Mailing Address - Fax:
Practice Address - Street 1:3388 PRINCESS ANNE RD STE 2001
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-2612
Practice Address - Country:US
Practice Address - Phone:757-507-7271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040174661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical