Provider Demographics
NPI:1801322367
Name:HENDRICKSON, MALLORY
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 E 1650 S
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-8061
Mailing Address - Country:US
Mailing Address - Phone:801-946-0059
Mailing Address - Fax:
Practice Address - Street 1:744 E 1650 S
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097
Practice Address - Country:US
Practice Address - Phone:801-946-0059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst