Provider Demographics
NPI:1356800577
Name:BITTERMAN, MALLORY M
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:M
Last Name:BITTERMAN
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 1:124 ASBURY DR
Mailing Address - Street 2:
Mailing Address - City:WILMORE
Mailing Address - State:KY
Mailing Address - Zip Code:40390-1115
Mailing Address - Country:US
Mailing Address - Phone:765-480-3259
Mailing Address - Fax:
Practice Address - Street 1:124 ASBURY DR
Practice Address - Street 2:
Practice Address - City:WILMORE
Practice Address - State:KY
Practice Address - Zip Code:40390-1115
Practice Address - Country:US
Practice Address - Phone:765-480-3259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1256Medicaid