Provider Demographics
NPI:1427521707
Name:MCCLAIN, MALLORY ANN (RBT)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:ANN
Last Name:MCCLAIN
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 CARRIER DR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-8416
Mailing Address - Country:US
Mailing Address - Phone:904-827-3886
Mailing Address - Fax:
Practice Address - Street 1:101 MARKETSIDE AVE STE 404-411
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-1541
Practice Address - Country:US
Practice Address - Phone:904-827-3886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19-75520106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician