Provider Demographics
NPI:1962288134
Name:WILLBANKS, MALLORY ROCHELLO (BT)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:ROCHELLO
Last Name:WILLBANKS
Suffix:
Gender:F
Credentials:BT
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:ROCHELLO
Other - Last Name:WILLBANKS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BT
Mailing Address - Street 1:2808 FOX MEADOW LANE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-9346
Mailing Address - Country:US
Mailing Address - Phone:870-335-2240
Mailing Address - Fax:870-931-4457
Practice Address - Street 1:2808 FOX MEADOW LANE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72404-9346
Practice Address - Country:US
Practice Address - Phone:870-335-2240
Practice Address - Fax:870-931-4457
Is Sole Proprietor?:No
Enumeration Date:2023-09-05
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst