1447716246 NPI number — MALLIE DANIELLE UNDERWOOD LCSW

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447716246 NPI number — MALLIE DANIELLE UNDERWOOD LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
UNDERWOOD
Provider First Name:
MALLIE
Provider Middle Name:
DANIELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447716246
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1221 W BEN WHITE BLVD STE 210A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78704-7182
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-960-4533
Provider Business Mailing Address Fax Number:
512-703-1394

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1221 W BEN WHITE BLVD
Provider Second Line Business Practice Location Address:
STE 210A
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78704-7182
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-472-4357
Provider Business Practice Location Address Fax Number:
512-703-1394
Provider Enumeration Date:
02/17/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  59323 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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