Provider Demographics
NPI:1013758614
Name:WINE, MALLORY (CF, SLP)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:WINE
Suffix:
Gender:F
Credentials:CF, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13819 IRONTON CUT OFF RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72206-5279
Mailing Address - Country:US
Mailing Address - Phone:501-765-2881
Mailing Address - Fax:
Practice Address - Street 1:824 N TYLER ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-3535
Practice Address - Country:US
Practice Address - Phone:501-664-2961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR202687235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist