Provider Demographics
NPI:1740956747
Name:NELSON, MALLORY (SSP)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:SSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 US ROUTE 34
Mailing Address - Street 2:
Mailing Address - City:BIGGSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61418-5012
Mailing Address - Country:US
Mailing Address - Phone:309-627-2371
Mailing Address - Fax:
Practice Address - Street 1:1514 US ROUTE 34
Practice Address - Street 2:
Practice Address - City:BIGGSVILLE
Practice Address - State:IL
Practice Address - Zip Code:61418-5012
Practice Address - Country:US
Practice Address - Phone:309-627-2371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool