Provider Demographics
NPI:1609508753
Name:ROBERTSON, MALLORY
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:
Other - Last Name:MIXON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1522 CANAL ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-6025
Mailing Address - Country:US
Mailing Address - Phone:405-612-8730
Mailing Address - Fax:
Practice Address - Street 1:105 S BLAIR ST
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-4410
Practice Address - Country:US
Practice Address - Phone:479-259-2339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR201904235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist