Provider Demographics
NPI:1598414757
Name:MALLORY, KIMBERLY E (BA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:E
Last Name:MALLORY
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19199 APPOLINE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-1214
Mailing Address - Country:US
Mailing Address - Phone:248-403-9300
Mailing Address - Fax:
Practice Address - Street 1:1121 E MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48203-2857
Practice Address - Country:US
Practice Address - Phone:313-324-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-23
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator