Healthcare Provider Details

I. General information

NPI: 1821664087
Provider Name (Legal Business Name): MALLORY B STAGGS SLP-CCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2021
Last Update Date: 05/28/2021
Certification Date: 05/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2388 WILLOW LENOXBURG RD
BROOKSVILLE KY
41004-8514
US

IV. Provider business mailing address

2388 WILLOW LENOXBURG RD
BROOKSVILLE KY
41004-8514
US

V. Phone/Fax

Practice location:
  • Phone: 606-782-5435
  • Fax:
Mailing address:
  • Phone: 606-782-5435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number140617
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: