Provider Demographics
NPI:1831567726
Name:WEBER, MALLORY CLARE
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:CLARE
Last Name:WEBER
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 1:1002 SHERWOOD PARK
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-3164
Mailing Address - Country:US
Mailing Address - Phone:217-821-9980
Mailing Address - Fax:
Practice Address - Street 1:1901 S 4TH ST STE 219
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-4187
Practice Address - Country:US
Practice Address - Phone:217-821-9980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL011141101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional