Provider Demographics
NPI:1962052290
Name:MYERS, MALLORY ANN
Entity type:Individual
Prefix:MISS
First Name:MALLORY
Middle Name:ANN
Last Name:MYERS
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 1:1680 S GAREY AVE UNIT 306
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-5289
Mailing Address - Country:US
Mailing Address - Phone:805-390-0804
Mailing Address - Fax:
Practice Address - Street 1:2501 W EL SEGUNDO BLVD
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-3317
Practice Address - Country:US
Practice Address - Phone:323-754-2816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)