Healthcare Provider Details

I. General information

NPI: 1568138949
Provider Name (Legal Business Name): MALLORY L WARREN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2021
Last Update Date: 04/19/2022
Certification Date: 04/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1484 N M 52
OWOSSO MI
48867-1235
US

IV. Provider business mailing address

202 PINE ST
CHESANING MI
48616-1252
US

V. Phone/Fax

Practice location:
  • Phone: 770-373-5822
  • Fax:
Mailing address:
  • Phone: 989-323-2090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: