Basic Information
| Provider Information | |||||||||
| NPI: | 1912392143 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DANGELO | ||||||||
| FirstName: | MALLORY | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KOLICH | ||||||||
| OtherFirstName: | MALLORY | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5655 HUDSON DR STE 305 | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442364454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306502111 | ||||||||
| FaxNumber: | 3306502211 | ||||||||
| Practice Location | |||||||||
| Address1: | 5655 HUDSON DR STE 305 | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442364454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306502111 | ||||||||
| FaxNumber: | 3306502211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2015 | ||||||||
| LastUpdateDate: | 03/11/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 34.012488 | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.