Provider Demographics
NPI:1457097149
Name:MAYER, MALLORY BROOKE
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:BROOKE
Last Name:MAYER
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 1:7721 PRIMROSE LN
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4941
Mailing Address - Country:US
Mailing Address - Phone:616-566-6051
Mailing Address - Fax:
Practice Address - Street 1:229 E MICHIGAN AVE STE 345
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-6403
Practice Address - Country:US
Practice Address - Phone:269-993-4373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-06
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011145421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical