Basic Information
Provider Information
NPI: 1003142340
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LIIV
FirstName: ERIN
MiddleName: O.
NamePrefix: MRS.
NameSuffix:  
Credential: LCSW
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: MALLORY
OtherFirstName: ERIN
OtherMiddleName: O.
OtherNamePrefix: MS.
OtherNameSuffix:  
OtherCredential: LCSW
OtherLastNameType: 1
Mailing Information
Address1: PO BOX 49
Address2:  
City: BODEGA
State: CA
PostalCode: 949220049
CountryCode: US
TelephoneNumber: 7072286275
FaxNumber:  
Practice Location
Address1: 1300 N DUTTON AVE
Address2:  
City: SANTA ROSA
State: CA
PostalCode: 954017112
CountryCode: US
TelephoneNumber: 7073033600
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/21/2009
LastUpdateDate: 08/19/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1041C0700XLCS23841CAY Behavioral Health & Social Service ProvidersSocial WorkerClinical

No ID Information.


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