Provider Demographics
NPI:1053094938
Name:MALLORY, MONAE L
Entity type:Individual
Prefix:
First Name:MONAE
Middle Name:L
Last Name:MALLORY
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 1:1909 E GUM AVE
Mailing Address - Street 2:
Mailing Address - City:REEDLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93654-8867
Mailing Address - Country:US
Mailing Address - Phone:559-726-0587
Mailing Address - Fax:
Practice Address - Street 1:795 FOLSOM ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94107-1243
Practice Address - Country:US
Practice Address - Phone:904-638-6388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-23-289564106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician