Provider Demographics
NPI:1477066280
Name:GEORGE, MALLORY L (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:L
Last Name:GEORGE
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 261092
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75026-1092
Mailing Address - Country:US
Mailing Address - Phone:972-232-7474
Mailing Address - Fax:972-232-7401
Practice Address - Street 1:7273 HAWKINS VIEW DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-3921
Practice Address - Country:US
Practice Address - Phone:972-232-7474
Practice Address - Fax:972-232-7401
Is Sole Proprietor?:No
Enumeration Date:2017-11-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP135789363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX382244702Medicaid
TXXG4602353OtherDATA 2000 WAIVER
TXAP135789OtherLICENSE
TXAP135789OtherLICENSE