Provider Demographics
NPI:1992335673
Name:THOMSEN, MALLORY GRACIA-ROSE (LCSW, LMSW, MSW)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:GRACIA-ROSE
Last Name:THOMSEN
Suffix:
Gender:F
Credentials:LCSW, LMSW, MSW
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:
Other - Last Name:SPRAGUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2114 DELAWARE DR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-6017
Mailing Address - Country:US
Mailing Address - Phone:616-320-2021
Mailing Address - Fax:
Practice Address - Street 1:2114 DELAWARE DR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-6017
Practice Address - Country:US
Practice Address - Phone:616-320-2021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-22
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
NY0956481041C0700X
MI68011176591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker