Provider Demographics
NPI:1356598486
Name:BAUM, MALLORY LYNN (LMFT)
Entity type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:LYNN
Last Name:BAUM
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1434 S ELLIS ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67211-3527
Mailing Address - Country:US
Mailing Address - Phone:316-204-1584
Mailing Address - Fax:206-299-1262
Practice Address - Street 1:606 N. MULBERRY
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037
Practice Address - Country:US
Practice Address - Phone:316-788-6464
Practice Address - Fax:206-299-1262
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1054106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200574520AMedicaid