Provider Demographics
NPI:1639244080
Name:MALLORY, STEVEN MICHAEL (LPC LADC)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:MICHAEL
Last Name:MALLORY
Suffix:
Gender:M
Credentials:LPC LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:OK
Mailing Address - Zip Code:74637-3023
Mailing Address - Country:US
Mailing Address - Phone:918-642-3100
Mailing Address - Fax:918-642-3100
Practice Address - Street 1:1500 NORTH 6TH STREET
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601
Practice Address - Country:US
Practice Address - Phone:580-762-7561
Practice Address - Fax:580-762-5876
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK476101YA0400X
OKLPC1418101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)