Provider Demographics
NPI:1891314530
Name:SMITH, MALLORY E (LBA, BCBA)
Entity Type:Individual
Prefix:MS
First Name:MALLORY
Middle Name:E
Last Name:SMITH
Suffix:
Gender:F
Credentials:LBA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1426B STAINBACK AVE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37207-5134
Mailing Address - Country:US
Mailing Address - Phone:615-310-6527
Mailing Address - Fax:
Practice Address - Street 1:401 S MOUNT JULIET RD STE 235-118
Practice Address - Street 2:
Practice Address - City:MT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-6359
Practice Address - Country:US
Practice Address - Phone:615-393-1709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-13
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN236103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst