Provider Demographics
NPI:1720610645
Name:ROBERTS, MALLORY
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:ROBERTS
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 1:2662 JOSHUA WAY
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-8953
Mailing Address - Country:US
Mailing Address - Phone:801-663-9765
Mailing Address - Fax:
Practice Address - Street 1:302 2ND AVE E
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6425
Practice Address - Country:US
Practice Address - Phone:208-749-3475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-08
Last Update Date:2020-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-4224235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist