Provider Demographics
NPI:1568138949
Name:WARREN, MALLORY L
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:L
Last Name:WARREN
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 1:202 PINE ST
Mailing Address - Street 2:
Mailing Address - City:CHESANING
Mailing Address - State:MI
Mailing Address - Zip Code:48616-1252
Mailing Address - Country:US
Mailing Address - Phone:989-323-2090
Mailing Address - Fax:
Practice Address - Street 1:1484 N M 52
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-1235
Practice Address - Country:US
Practice Address - Phone:770-373-5822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-17
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician