Healthcare Provider Details

I. General information

NPI: 1215103593
Provider Name (Legal Business Name): LAURA MALLORY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2008
Last Update Date: 01/09/2023
Certification Date: 01/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 E CANAL DR
TURLOCK CA
95380-3936
US

IV. Provider business mailing address

420 E CANAL DR
TURLOCK CA
95380-3936
US

V. Phone/Fax

Practice location:
  • Phone: 209-669-2583
  • Fax: 209-669-2588
Mailing address:
  • Phone: 209-669-2583
  • Fax: 209-669-2588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number67740
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number103976
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: