Provider Demographics
NPI:1053028183
Name:KOLP, MALORY DIANE (LMSW)
Entity type:Individual
Prefix:
First Name:MALORY
Middle Name:DIANE
Last Name:KOLP
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1156 MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72019-8789
Mailing Address - Country:US
Mailing Address - Phone:501-802-4317
Mailing Address - Fax:
Practice Address - Street 1:515 OAK ST STE E
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-4464
Practice Address - Country:US
Practice Address - Phone:501-697-8053
Practice Address - Fax:501-232-4130
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-28
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR11919-M104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker