Provider Demographics
NPI:1639777618
Name:SMITHART, MALLORY ELIZABETH
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:ELIZABETH
Last Name:SMITHART
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 1:13825 US HIGHWAY 29
Mailing Address - Street 2:
Mailing Address - City:ANDALUSIA
Mailing Address - State:AL
Mailing Address - Zip Code:36420-7233
Mailing Address - Country:US
Mailing Address - Phone:334-892-4311
Mailing Address - Fax:
Practice Address - Street 1:1247 RUCKER BLVD STE 3
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-3630
Practice Address - Country:US
Practice Address - Phone:334-347-5003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician