Provider Demographics
NPI:1043947997
Name:UNDERWOOD MALLORY, KALEIGH JOY
Entity Type:Individual
Prefix:
First Name:KALEIGH
Middle Name:JOY
Last Name:UNDERWOOD MALLORY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 E RADCLIFF ST
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74352-5015
Mailing Address - Country:US
Mailing Address - Phone:918-605-9380
Mailing Address - Fax:
Practice Address - Street 1:109 N FAIRLAND ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-4205
Practice Address - Country:US
Practice Address - Phone:844-458-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst