Healthcare Provider Details

I. General information

NPI: 1275020018
Provider Name (Legal Business Name): MALLORI VOGELPOHL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 04/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 E MAIN ST
NEW LONDON IA
52645-1218
US

IV. Provider business mailing address

132 POLK ST
BURLINGTON IA
52601-6158
US

V. Phone/Fax

Practice location:
  • Phone: 319-931-7169
  • Fax:
Mailing address:
  • Phone: 217-491-2761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number075743
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: