Provider Demographics
NPI:1316401433
Name:NIEMCZYK, MALLORY NICOLE
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:NICOLE
Last Name:NIEMCZYK
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 1:7375 WOODWARD AVE STE 2800
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3157
Mailing Address - Country:US
Mailing Address - Phone:906-869-7917
Mailing Address - Fax:
Practice Address - Street 1:7375 WOODWARD AVE STE 2800
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3157
Practice Address - Country:US
Practice Address - Phone:069-869-7917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2023-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI7401001242103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician