Healthcare Provider Details

I. General information

NPI: 1033766704
Provider Name (Legal Business Name): MALLORY MARIE MCCORKLE MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2019
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 POLY PL
BROOKLYN NY
11209-7104
US

IV. Provider business mailing address

11059 E BETHANY DR STE 238
AURORA CO
80014-2622
US

V. Phone/Fax

Practice location:
  • Phone: 718-836-6600
  • Fax:
Mailing address:
  • Phone: 303-617-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: