Provider Demographics
NPI:1942765904
Name:ADAMS, MALLORY DENNE (RBT)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:DENNE
Last Name:ADAMS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:358 S 700 E STE B307
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2161
Mailing Address - Country:US
Mailing Address - Phone:316-558-0288
Mailing Address - Fax:
Practice Address - Street 1:233 S 400 W APT 3
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-5147
Practice Address - Country:US
Practice Address - Phone:316-558-0288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTRBT-18-70165106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician