Provider Demographics
NPI:1720835341
Name:DAUGHETY, MALLORY ELIZABETH
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:ELIZABETH
Last Name:DAUGHETY
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 1:54 E GORDON AVE
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-2528
Mailing Address - Country:US
Mailing Address - Phone:252-229-3054
Mailing Address - Fax:
Practice Address - Street 1:375 N MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:KAYSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84037-1272
Practice Address - Country:US
Practice Address - Phone:801-989-3488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-01
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13430185-3904106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist