Healthcare Provider Details

I. General information

NPI: 1649194044
Provider Name (Legal Business Name): MALLORY ROBERTSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MALLORY CRAION

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 FOX DR STE D
CHAMPAIGN IL
61820-7280
US

IV. Provider business mailing address

1802 FOX DR STE D
CHAMPAIGN IL
61820-7280
US

V. Phone/Fax

Practice location:
  • Phone: 217-766-0258
  • Fax: 217-883-4030
Mailing address:
  • Phone: 217-766-0258
  • Fax: 217-883-4030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150119341
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: