Provider Demographics
NPI:1487126595
Name:BEARDSLEY, MALLORY
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:BEARDSLEY
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 1:701 MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2645
Mailing Address - Country:US
Mailing Address - Phone:989-239-0870
Mailing Address - Fax:
Practice Address - Street 1:132 E GRAND RIVER AVE STE 205
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-1510
Practice Address - Country:US
Practice Address - Phone:989-239-0870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-31
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401018036101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6401018036Medicaid