Healthcare Provider Details

I. General information

NPI: 1801322367
Provider Name (Legal Business Name): MALLORY HENDRICKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2017
Last Update Date: 05/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 E 1650 S
OREM UT
84097
US

IV. Provider business mailing address

744 E 1650 S
OREM UT
84097-8061
US

V. Phone/Fax

Practice location:
  • Phone: 801-946-0059
  • Fax:
Mailing address:
  • Phone: 801-946-0059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: