Provider Demographics
NPI:1831998764
Name:MALLORY, TYLER (CPS,CHW-C)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:MALLORY
Suffix:
Gender:
Credentials:CPS,CHW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 W HILL ST
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65259-1197
Mailing Address - Country:US
Mailing Address - Phone:660-651-9102
Mailing Address - Fax:
Practice Address - Street 1:105 S WEBER AVE
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MO
Practice Address - Zip Code:65281-1071
Practice Address - Country:US
Practice Address - Phone:660-338-5001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-12
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO17723175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty