Provider Demographics
NPI:1073875696
Name:HENDRICKS, MALLORY ANNETTE (MSED)
Entity Type:Individual
Prefix:MS
First Name:MALLORY
Middle Name:ANNETTE
Last Name:HENDRICKS
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 WESTCHESTER AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-3512
Mailing Address - Country:US
Mailing Address - Phone:718-597-5558
Mailing Address - Fax:
Practice Address - Street 1:2510 WESTCHESTER AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-3512
Practice Address - Country:US
Practice Address - Phone:718-597-5558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-10
Last Update Date:2012-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1809831174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist