MEDICARE: MS. CHERYL B MALLORY LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LPC-13231	AZ

General Provider Information

NPI Number	:	1457531444
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CHERYL B MALLORY LPC

Provider Business Mailing Address
First Line	:	2152 S VINEYARD STE 110
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85210-6881
Country	:	US
Telephone Number	:	480-507-3340
Fax Number	:	480-507-3317

Provider Business Practice Location Address
First Line	:	2152 S VINEYARD STE 110
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85210-6881
Country	:	US
Telephone Number	:	480-507-3340
Fax Number	:	480-507-3317

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2007
Last Update Date	:	03/01/2021

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