Healthcare Provider Details

I. General information

NPI: 1184066011
Provider Name (Legal Business Name): MALLORY LINAM WILKERSON BCABA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2013
Last Update Date: 10/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SILVERTON CIR
MADISON AL
35758-7642
US

IV. Provider business mailing address

100 SILVERTON CIR
MADISON AL
35758-7642
US

V. Phone/Fax

Practice location:
  • Phone: 256-679-3814
  • Fax:
Mailing address:
  • Phone: 256-679-3814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0-13-5427
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-13-5427
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: