Provider Demographics
NPI:1699014829
Name:MALLORY, AMANDA LEEANN (LCSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEEANN
Last Name:MALLORY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 GREAT OAKS DR.
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-4325
Mailing Address - Country:US
Mailing Address - Phone:405-808-5163
Mailing Address - Fax:
Practice Address - Street 1:909 ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-5229
Practice Address - Country:US
Practice Address - Phone:405-573-3921
Practice Address - Fax:405-573-8245
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OK5133-P1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator