Provider Demographics
NPI:1881185346
Name:DEERING, MALLORY (RBT-16-24272)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:DEERING
Suffix:
Gender:F
Credentials:RBT-16-24272
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11112 S HOMAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-3504
Mailing Address - Country:US
Mailing Address - Phone:815-616-2127
Mailing Address - Fax:
Practice Address - Street 1:11112 S HOMAN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-3504
Practice Address - Country:US
Practice Address - Phone:815-616-2127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL16-24272106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician