Provider Demographics
NPI:1225666597
Name:MALLORY, GWENDOLYN (QMHA)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:MALLORY
Suffix:
Gender:F
Credentials:QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4550 W SAHARA AVE APT 1241
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-3648
Mailing Address - Country:US
Mailing Address - Phone:909-600-8373
Mailing Address - Fax:
Practice Address - Street 1:4550 W SAHARA AVE APT 1241
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-3648
Practice Address - Country:US
Practice Address - Phone:909-600-8373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-31
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV02632-I101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)