Provider Demographics
NPI:1306348859
Name:HERNDON, MALLORY KATHLEEN
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:KATHLEEN
Last Name:HERNDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:KATHLEEN
Other - Last Name:HERNDON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:106S00000X
Mailing Address - Street 1:458 BARCELONA RD
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909
Mailing Address - Country:US
Mailing Address - Phone:321-795-2670
Mailing Address - Fax:
Practice Address - Street 1:458 BARCELONA RD
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909
Practice Address - Country:US
Practice Address - Phone:321-795-2670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-01
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106S00000XMedicaid