Provider Demographics
NPI:1134701469
Name:GAKPO, MALLORY W
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:W
Last Name:GAKPO
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 1:4925 DUNLIN DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46235-0014
Mailing Address - Country:US
Mailing Address - Phone:317-694-9702
Mailing Address - Fax:
Practice Address - Street 1:501 S 9TH ST STE 108
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-2709
Practice Address - Country:US
Practice Address - Phone:317-333-6838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33008825A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health