Provider Demographics
NPI:1386253797
Name:SPENCE, MALLORY JO (MSW, LCASA, LCSWA)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:JO
Last Name:SPENCE
Suffix:
Gender:F
Credentials:MSW, LCASA, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3825 MARKET ST STE 4
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-1426
Mailing Address - Country:US
Mailing Address - Phone:910-777-5575
Mailing Address - Fax:910-777-5273
Practice Address - Street 1:3825 MARKET ST STE 4
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-1426
Practice Address - Country:US
Practice Address - Phone:910-777-5575
Practice Address - Fax:910-777-5273
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-31
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-25514101YA0400X
NCP0142581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty