Provider Demographics
NPI:1952326001
Name:MALLORY, CHARLES HAYS (PHD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:HAYS
Last Name:MALLORY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4313 W MARKHAM ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-4023
Mailing Address - Country:US
Mailing Address - Phone:501-666-0236
Mailing Address - Fax:501-686-9276
Practice Address - Street 1:4313 W MARKHAM ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-4023
Practice Address - Country:US
Practice Address - Phone:501-666-0236
Practice Address - Fax:501-686-9276
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR7513P103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR56309Medicare ID - Type Unspecified