Provider Demographics
NPI:1376128603
Name:DILL, MALLORY MCKNIGHT
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:MCKNIGHT
Last Name:DILL
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 1:56 HORSESHOE DR
Mailing Address - Street 2:
Mailing Address - City:MERIGOLD
Mailing Address - State:MS
Mailing Address - Zip Code:38759-9658
Mailing Address - Country:US
Mailing Address - Phone:662-719-8757
Mailing Address - Fax:
Practice Address - Street 1:212 N CHRISMAN AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2730
Practice Address - Country:US
Practice Address - Phone:662-719-2505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0536101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty