Provider Demographics
NPI:1922590918
Name:MALLORY, KATHRYN CHATTERTON (LPS)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:CHATTERTON
Last Name:MALLORY
Suffix:
Gender:F
Credentials:LPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 SLATER ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-2923
Mailing Address - Country:US
Mailing Address - Phone:907-457-1101
Mailing Address - Fax:907-457-1121
Practice Address - Street 1:318 SLATER ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-2923
Practice Address - Country:US
Practice Address - Phone:907-457-1101
Practice Address - Fax:907-457-1121
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-05
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
AK135481101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1596091Medicaid