Provider Demographics
NPI:1558940601
Name:WOFFORD, MALLORY JAYNE
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:JAYNE
Last Name:WOFFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:JAYNE
Other - Last Name:LIESENFELDER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3511 CHICAGO AVE APT P
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-4438
Mailing Address - Country:US
Mailing Address - Phone:626-367-3139
Mailing Address - Fax:
Practice Address - Street 1:1151 DOVE ST
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2840
Practice Address - Country:US
Practice Address - Phone:949-630-8290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-06
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician