Provider Demographics
NPI:1932792496
Name:CALLANS, MALLORY A
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:A
Last Name:CALLANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6305 JEFFERSON CIR S
Mailing Address - Street 2:
Mailing Address - City:CHAMBLEE
Mailing Address - State:GA
Mailing Address - Zip Code:30341-2663
Mailing Address - Country:US
Mailing Address - Phone:941-504-4046
Mailing Address - Fax:
Practice Address - Street 1:2002 MACY DR
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-6346
Practice Address - Country:US
Practice Address - Phone:678-400-9477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-16
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health