Provider Demographics
NPI:1720676083
Name:MALLORY, TRAVIS MAURICE
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:MAURICE
Last Name:MALLORY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5308 S 65TH STREET CIR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-2382
Mailing Address - Country:US
Mailing Address - Phone:402-480-5306
Mailing Address - Fax:
Practice Address - Street 1:2641 S 70TH ST STE A
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-2912
Practice Address - Country:US
Practice Address - Phone:402-327-9711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-04
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NECPSS-070104100000X
NE101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker