Provider Demographics
NPI:1770142887
Name:GRIFFIN, MALLORY TQ (RBT)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:TQ
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SPENRYN DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-1890
Mailing Address - Country:US
Mailing Address - Phone:256-772-4400
Mailing Address - Fax:
Practice Address - Street 1:2117 METRO CIR SW # A
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-5343
Practice Address - Country:US
Practice Address - Phone:256-701-3134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-12
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL17-31784106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician