Provider Demographics
NPI:1659824308
Name:MALLORY, YVETTE (PSYD)
Entity type:Individual
Prefix:
First Name:YVETTE
Middle Name:
Last Name:MALLORY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11205 LEBANON RD PMB 1008
Mailing Address - Street 2:
Mailing Address - City:MT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11205 LEBANON RD PMB 1008
Practice Address - Street 2:
Practice Address - City:MT. JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122
Practice Address - Country:US
Practice Address - Phone:615-412-8909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-29
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 9599103T00000X
TN3980103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103T00000XBehavioral Health & Social Service ProvidersPsychologist