Provider Demographics
NPI:1437769189
Name:MALLORY, KELLAN
Entity Type:Individual
Prefix:
First Name:KELLAN
Middle Name:
Last Name:MALLORY
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 1:2012 WHITEOAK CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:WV
Mailing Address - Zip Code:24712-9676
Mailing Address - Country:US
Mailing Address - Phone:304-887-5357
Mailing Address - Fax:
Practice Address - Street 1:120 HANWORTH LN
Practice Address - Street 2:
Practice Address - City:DANIELS
Practice Address - State:WV
Practice Address - Zip Code:25832-9029
Practice Address - Country:US
Practice Address - Phone:304-887-5357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-07
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist