Provider Demographics
NPI:1821664087
Name:STAGGS, MALLORY B (SLP-CCC)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:B
Last Name:STAGGS
Suffix:
Gender:F
Credentials:SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2388 WILLOW LENOXBURG RD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41004-8514
Mailing Address - Country:US
Mailing Address - Phone:606-782-5435
Mailing Address - Fax:
Practice Address - Street 1:2388 WILLOW LENOXBURG RD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41004-8514
Practice Address - Country:US
Practice Address - Phone:606-782-5435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-28
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY140617235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist