Provider Demographics
NPI:1659680262
Name:MARDIS, MALLARY MCLEMORE (CFY-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MALLARY
Middle Name:MCLEMORE
Last Name:MARDIS
Suffix:
Gender:F
Credentials:CFY-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 PRESCOTT RDG
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-4725
Mailing Address - Country:US
Mailing Address - Phone:601-540-4476
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-4550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-29
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3445235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS302I151436OtherMEDICARE PTAN UMC
MS302I151435OtherMEDICARE PTAN UP
MS05401310Medicaid