Provider Demographics
NPI:1942992375
Name:PARK, MALLORY MARIAN
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:MARIAN
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5406 MERLE HAY RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:IA
Mailing Address - Zip Code:50131-1209
Mailing Address - Country:US
Mailing Address - Phone:515-727-8750
Mailing Address - Fax:515-727-8757
Practice Address - Street 1:1661 BOYSON SQUARE DR STE 100
Practice Address - Street 2:
Practice Address - City:HIAWATHA
Practice Address - State:IA
Practice Address - Zip Code:52233-2392
Practice Address - Country:US
Practice Address - Phone:319-777-7450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA114914235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist