Provider Demographics
NPI:1598338493
Name:PLATTE, MALLORY
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:PLATTE
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 1:7303 WILLOW PARK DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33637-6461
Mailing Address - Country:US
Mailing Address - Phone:512-968-8397
Mailing Address - Fax:
Practice Address - Street 1:14497 N DALE MABRY HWY STE 115N
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2023
Practice Address - Country:US
Practice Address - Phone:813-814-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-21-169478106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician