Provider Demographics
NPI:1114755402
Name:DAVILA, MALLORY LEIGH (MS)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:LEIGH
Last Name:DAVILA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 E 63RD ST STE 240
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64110-3331
Mailing Address - Country:US
Mailing Address - Phone:816-756-3505
Mailing Address - Fax:
Practice Address - Street 1:633 E 63RD ST STE 240
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64110-3331
Practice Address - Country:US
Practice Address - Phone:816-673-6769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-26
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024029167101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health