Provider Demographics
NPI:1275987711
Name:SANAIE, MALLORY (MA CF-SLP)
Entity Type:Individual
Prefix:MISS
First Name:MALLORY
Middle Name:
Last Name:SANAIE
Suffix:
Gender:F
Credentials:MA CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 STAN WALL RD
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-9827
Mailing Address - Country:US
Mailing Address - Phone:318-267-2597
Mailing Address - Fax:
Practice Address - Street 1:1605 STUBBS AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5629
Practice Address - Country:US
Practice Address - Phone:318-372-9732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-21
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7372235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist