Provider Demographics
NPI:1164736591
Name:FRIERSON, MALLARY (SLPA)
Entity Type:Individual
Prefix:
First Name:MALLARY
Middle Name:
Last Name:FRIERSON
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 PATRIOT PKWY
Mailing Address - Street 2:
Mailing Address - City:VENUS
Mailing Address - State:TX
Mailing Address - Zip Code:76084-3728
Mailing Address - Country:US
Mailing Address - Phone:817-433-0721
Mailing Address - Fax:
Practice Address - Street 1:5306 TRAIL LAKE DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133-1931
Practice Address - Country:US
Practice Address - Phone:817-433-0721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-27
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32980235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149984001Medicaid
TX676535Medicare UPIN
TX149984001Medicaid