Provider Demographics
NPI:1104645928
Name:MALLORY, CHASITY
Entity type:Individual
Prefix:
First Name:CHASITY
Middle Name:
Last Name:MALLORY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 REFLECTIONS CIRCLE
Mailing Address - Street 2:APT 207
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707
Mailing Address - Country:US
Mailing Address - Phone:470-998-1751
Mailing Address - Fax:
Practice Address - Street 1:2479 ALOMA AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-2541
Practice Address - Country:US
Practice Address - Phone:407-657-6692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-08
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
BACB1144930103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst