Provider Demographics
NPI:1346017803
Name:SMITH, MALLORY BROOKE (MA, LPCC)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:BROOKE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18309 E MAINSTREET APT 13304
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-4504
Mailing Address - Country:US
Mailing Address - Phone:620-253-3385
Mailing Address - Fax:
Practice Address - Street 1:18309 E MAINSTREET APT 13304
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134-4504
Practice Address - Country:US
Practice Address - Phone:620-253-3385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO.0021419101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health