Provider Demographics
NPI:1801440110
Name:MAHAN, MALLORY
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:MAHAN
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 1:606 E SPRING ST
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-5066
Mailing Address - Country:US
Mailing Address - Phone:931-303-0665
Mailing Address - Fax:
Practice Address - Street 1:606 E SPRING ST
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-5066
Practice Address - Country:US
Practice Address - Phone:931-303-0665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-25
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN000609761101YS0200X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool