Provider Demographics
NPI:1043803489
Name:LOWERY, MALLORY BRIANNE (RBT)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:BRIANNE
Last Name:LOWERY
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 CHOWNING AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-5132
Mailing Address - Country:US
Mailing Address - Phone:405-465-3639
Mailing Address - Fax:
Practice Address - Street 1:13905 TECHNOLOGY DR STE 1A
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-1054
Practice Address - Country:US
Practice Address - Phone:539-777-0940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-17
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKRBT-21-156107106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKYUQ897055988OtherBLUE CROSS BLUE SHIELD