Provider Demographics
NPI:1669084398
Name:BROWN, MALLORY (BCBA)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7570 SADDLE CREEK TRL
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30506-5718
Mailing Address - Country:US
Mailing Address - Phone:770-883-4436
Mailing Address - Fax:
Practice Address - Street 1:102 MARY ALICE PARK RD STE 304
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2683
Practice Address - Country:US
Practice Address - Phone:443-414-1843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-24
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-20-44163103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty