Provider Demographics
NPI:1730471228
Name:MALLORY, WILLIAM FRANCIS (LADC)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:FRANCIS
Last Name:MALLORY
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 W 17TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH SIOUX CITY
Mailing Address - State:NE
Mailing Address - Zip Code:68776-2119
Mailing Address - Country:US
Mailing Address - Phone:402-878-2231
Mailing Address - Fax:402-878-2535
Practice Address - Street 1:HIGHWAY 75/77
Practice Address - Street 2:WINNEBAGO IHS HOSPITAL
Practice Address - City:WINNEBAGO
Practice Address - State:NE
Practice Address - Zip Code:68071-0767
Practice Address - Country:US
Practice Address - Phone:402-878-2231
Practice Address - Fax:402-878-2535
Is Sole Proprietor?:No
Enumeration Date:2011-05-03
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE100101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)