Provider Demographics
NPI:1760068803
Name:WALTERS, MALLORY (BCBA)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:WALTERS
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:
Other - Last Name:NICHOLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RBT
Mailing Address - Street 1:138 FIELD GROVE CT
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-4323
Mailing Address - Country:US
Mailing Address - Phone:713-732-7049
Mailing Address - Fax:
Practice Address - Street 1:138 FIELD GROVE CT
Practice Address - Street 2:
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-4323
Practice Address - Country:US
Practice Address - Phone:713-732-7049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-19
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-22-59328103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst