Provider Demographics
NPI:1407065360
Name:MALLON, JANIS CAROL (PHD)
Entity type:Individual
Prefix:DR
First Name:JANIS
Middle Name:CAROL
Last Name:MALLON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 EDES RD
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04021-4101
Mailing Address - Country:US
Mailing Address - Phone:207-829-6912
Mailing Address - Fax:
Practice Address - Street 1:26 EDES RD
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:ME
Practice Address - Zip Code:04021-4101
Practice Address - Country:US
Practice Address - Phone:207-829-6912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS692103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical