Provider Demographics
NPI:1215103593
Name:MALLORY, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
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 1:420 E CANAL DR
Mailing Address - Street 2:
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95380-3936
Mailing Address - Country:US
Mailing Address - Phone:209-669-2583
Mailing Address - Fax:209-669-2588
Practice Address - Street 1:420 E CANAL DR
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95380-3936
Practice Address - Country:US
Practice Address - Phone:209-669-2583
Practice Address - Fax:209-669-2588
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA67740101YP2500X
CA103976106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional