Provider Demographics
NPI:1306253638
Name:CARR, MALLORY
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:CARR
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 1:9135 N MERIDIAN ST STE A4
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1815
Mailing Address - Country:US
Mailing Address - Phone:317-937-0149
Mailing Address - Fax:
Practice Address - Street 1:9135 N MERIDIAN ST STE A4
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1815
Practice Address - Country:US
Practice Address - Phone:317-937-0149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-18
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39002571A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health