Healthcare Provider Details

I. General information

NPI: 1770288128
Provider Name (Legal Business Name): MALLORY ALISE WORREL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2023
Last Update Date: 04/18/2023
Certification Date: 04/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1602 N 2ND ST
CLINTON MO
64735-1192
US

IV. Provider business mailing address

417 N CARTER ST
DESLOGE MO
63601-2903
US

V. Phone/Fax

Practice location:
  • Phone: 660-890-7300
  • Fax:
Mailing address:
  • Phone: 808-597-0556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2022023146
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: