Provider Demographics
NPI:1972002368
Name:WARE, MALLORY
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:WARE
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:PO BOX 461
Mailing Address - Street 2:
Mailing Address - City:MORONI
Mailing Address - State:UT
Mailing Address - Zip Code:84646-0461
Mailing Address - Country:US
Mailing Address - Phone:435-262-1217
Mailing Address - Fax:
Practice Address - Street 1:19500 NORTH 2860 EAST
Practice Address - Street 2:
Practice Address - City:MORONI
Practice Address - State:UT
Practice Address - Zip Code:84646-0461
Practice Address - Country:US
Practice Address - Phone:435-262-1217
Practice Address - Fax:435-436-9029
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-12
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1235458555Medicaid