Provider Demographics
NPI:1134976368
Name:HABERLACK, MALLORY KATE
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:KATE
Last Name:HABERLACK
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 1:10251 RIDGELINE DR APT R184
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99338-5164
Mailing Address - Country:US
Mailing Address - Phone:509-947-1368
Mailing Address - Fax:
Practice Address - Street 1:3321 W KENNEWICK AVE STE 150
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-2968
Practice Address - Country:US
Practice Address - Phone:509-735-6446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist