Provider Demographics
NPI:1588070643
Name:DICKARD, MALLORY
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:DICKARD
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MALLORY
Other - Middle Name:
Other - Last Name:UPCHURCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:415 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-2319
Mailing Address - Country:US
Mailing Address - Phone:662-299-0049
Mailing Address - Fax:
Practice Address - Street 1:207 W JACKSON ST
Practice Address - Street 2:SUITE 2
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-2355
Practice Address - Country:US
Practice Address - Phone:601-362-0859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3872235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist