Provider Demographics
NPI:1679379879
Name:WALTZ, MALLORI (RBT)
Entity type:Individual
Prefix:
First Name:MALLORI
Middle Name:
Last Name:WALTZ
Suffix:
Gender:
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2231 GREGORY LN
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46012-9331
Mailing Address - Country:US
Mailing Address - Phone:765-615-6450
Mailing Address - Fax:
Practice Address - Street 1:5719 S MADISON AVE
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46013-1651
Practice Address - Country:US
Practice Address - Phone:765-617-2279
Practice Address - Fax:765-274-5244
Is Sole Proprietor?:No
Enumeration Date:2025-02-20
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-23-306247106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician