Provider Demographics
NPI:1215682042
Name:SIMMONS, MALLORY ALYSSE (LGPC)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:ALYSSE
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 E RIDGEVILLE BLVD # 312
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:MD
Mailing Address - Zip Code:21771-5201
Mailing Address - Country:US
Mailing Address - Phone:202-750-1028
Mailing Address - Fax:
Practice Address - Street 1:5656 JOSEPH CT
Practice Address - Street 2:
Practice Address - City:NEW MARKET
Practice Address - State:MD
Practice Address - Zip Code:21774
Practice Address - Country:US
Practice Address - Phone:202-750-1028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP10103101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional