Provider Demographics
NPI:1346807757
Name:MOTYCKA, MALLORY A
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:A
Last Name:MOTYCKA
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 1:6772 EAGLE ST
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-1141
Mailing Address - Country:US
Mailing Address - Phone:239-222-0186
Mailing Address - Fax:
Practice Address - Street 1:2001 BLUE HERON BLVD W
Practice Address - Street 2:
Practice Address - City:RIVIERA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33404-5003
Practice Address - Country:US
Practice Address - Phone:561-841-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor