Provider Demographics
NPI:1427752500
Name:PETERMAN, MALLORY BROOKE (LPC-A)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:BROOKE
Last Name:PETERMAN
Suffix:
Gender:F
Credentials:LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 LOVELOCK DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76108-7709
Mailing Address - Country:US
Mailing Address - Phone:817-201-0885
Mailing Address - Fax:
Practice Address - Street 1:1751 RIVER RUN STE 200
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-6670
Practice Address - Country:US
Practice Address - Phone:817-201-0885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-30
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX87951101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional