Provider Demographics
NPI:1427629468
Name:LEDOUX, MALLORY
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:LEDOUX
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 SW F AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73501-4542
Mailing Address - Country:US
Mailing Address - Phone:580-699-2700
Mailing Address - Fax:
Practice Address - Street 1:701 SW F AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-4542
Practice Address - Country:US
Practice Address - Phone:580-699-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-09
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0-23-14494106E00000X
TXRBT-21-173969106S00000X
OK1-25-79844103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician