Provider Demographics
NPI:1134836299
Name:TUCKER, MALLORY
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:TUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:
Other - Last Name:MILLSAP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4721 S CLIFF AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-6969
Mailing Address - Country:US
Mailing Address - Phone:816-608-1956
Mailing Address - Fax:800-687-5070
Practice Address - Street 1:96 GRASSO PLZ
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-3108
Practice Address - Country:US
Practice Address - Phone:636-398-2515
Practice Address - Fax:800-687-5070
Is Sole Proprietor?:No
Enumeration Date:2022-10-28
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-23-307541106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician