Provider Demographics
NPI:1013926385
Name:MALLARD, DAWN A (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:A
Last Name:MALLARD
Suffix:
Gender:F
Credentials:MA CCC-SLP
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 48116
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32247-8116
Mailing Address - Country:US
Mailing Address - Phone:904-725-1657
Mailing Address - Fax:904-725-7247
Practice Address - Street 1:880 A1A N
Practice Address - Street 2:STE 18A
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-3220
Practice Address - Country:US
Practice Address - Phone:904-778-7501
Practice Address - Fax:904-778-7504
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA5628235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist