Healthcare Provider Details

I. General information

NPI: 1972340834
Provider Name (Legal Business Name): MALLORY ROSE YEGGE LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2024
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2902 N ARMENIA AVE STE 200
TAMPA FL
33607-1661
US

IV. Provider business mailing address

2902 N ARMENIA AVE STE 200
TAMPA FL
33607-1661
US

V. Phone/Fax

Practice location:
  • Phone: 813-404-3962
  • Fax:
Mailing address:
  • Phone: 813-404-3962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number22894
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: