Provider Demographics
NPI:1689159477
Name:MALLIE, LAURIE (EDS)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:
Last Name:MALLIE
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5417 NW 108TH WAY
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33076-2744
Mailing Address - Country:US
Mailing Address - Phone:954-873-7624
Mailing Address - Fax:
Practice Address - Street 1:5417 NW 108TH WAY
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33076-2744
Practice Address - Country:US
Practice Address - Phone:954-873-7624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS1015103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty