Provider Demographics
NPI:1053140442
Name:MALLON, MADELEINE (LMSW)
Entity type:Individual
Prefix:
First Name:MADELEINE
Middle Name:
Last Name:MALLON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:MADELEINE
Other - Middle Name:
Other - Last Name:DELORIA-MANCINI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:165 MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-3191
Mailing Address - Country:US
Mailing Address - Phone:607-753-0234
Mailing Address - Fax:
Practice Address - Street 1:257 MAIN ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-2522
Practice Address - Country:US
Practice Address - Phone:607-729-6206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-01
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY110433104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker