Provider Demographics
NPI:1689393282
Name:OWEN, MALLARY ELLYN (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MALLARY
Middle Name:ELLYN
Last Name:OWEN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6146 SW 46TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-2818
Mailing Address - Country:US
Mailing Address - Phone:602-616-8248
Mailing Address - Fax:
Practice Address - Street 1:17020 SW UPPER BOONES FERRY RD STE 201
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97224-7078
Practice Address - Country:US
Practice Address - Phone:503-894-1539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17365235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist