Provider Demographics
NPI:1275242331
Name:DAIGLE, MALLORY SYDNEY
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:SYDNEY
Last Name:DAIGLE
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 1:758 ROYAL ST
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70802-6433
Mailing Address - Country:US
Mailing Address - Phone:225-276-8939
Mailing Address - Fax:
Practice Address - Street 1:758 ROYAL ST
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70802-6433
Practice Address - Country:US
Practice Address - Phone:225-529-3890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-17
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA010312193106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician