Provider Demographics
NPI:1487262713
Name:FENNELL, MALLERY (MS ED)
Entity type:Individual
Prefix:
First Name:MALLERY
Middle Name:
Last Name:FENNELL
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 ROSEDALE DR
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-2710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7 E CHEROKEE AVE
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-3302
Practice Address - Country:US
Practice Address - Phone:470-423-9477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-22
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist