Provider Demographics
NPI:1689218125
Name:CARPENTER, MALLORY RENEE (RSW)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:RENEE
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:RSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3927 UNION DR
Mailing Address - Street 2:
Mailing Address - City:ADDIS
Mailing Address - State:LA
Mailing Address - Zip Code:70710-2477
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11616 SOUTHFORK AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-5241
Practice Address - Country:US
Practice Address - Phone:225-291-9718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15608104100000X
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker