Provider Demographics
NPI:1144628124
Name:MALLORY, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MALLORY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1628 19TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79401-4832
Mailing Address - Country:US
Mailing Address - Phone:806-219-0500
Mailing Address - Fax:806-766-1286
Practice Address - Street 1:1628 19TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79401-4832
Practice Address - Country:US
Practice Address - Phone:806-219-0500
Practice Address - Fax:806-766-1286
Is Sole Proprietor?:No
Enumeration Date:2014-12-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional