Provider Demographics
NPI:1578092060
Name:SHARP, MALLORY (MA-CF, SLP)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:SHARP
Suffix:
Gender:F
Credentials:MA-CF, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 LANTERN LN
Mailing Address - Street 2:
Mailing Address - City:PLAIN CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43064-2104
Mailing Address - Country:US
Mailing Address - Phone:614-570-0185
Mailing Address - Fax:
Practice Address - Street 1:789 STONEYBROOK TRL
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-6021
Practice Address - Country:US
Practice Address - Phone:937-878-0262
Practice Address - Fax:937-878-8407
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2017220235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist