Healthcare Provider Details

I. General information

NPI: 1609604784
Provider Name (Legal Business Name): MALLARY VENABLE PARKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4721 DALE CURTIN DR
MCFARLAND WI
53558-8958
US

IV. Provider business mailing address

103 CANE HILL DR
BROUSSARD LA
70518-7459
US

V. Phone/Fax

Practice location:
  • Phone: 608-838-9482
  • Fax:
Mailing address:
  • Phone: 337-380-0091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7454-154
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number9648
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: