Provider Demographics
NPI:1033610993
Name:WALKER, MALLORY (BCBA, MED)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:WALKER
Suffix:
Gender:F
Credentials:BCBA, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 CHRISTOPHER AVE
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-2745
Mailing Address - Country:US
Mailing Address - Phone:408-309-7527
Mailing Address - Fax:
Practice Address - Street 1:3162 NEWBERRY DR STE 10
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95118-1567
Practice Address - Country:US
Practice Address - Phone:408-826-4828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician