Provider Demographics
NPI:1972108694
Name:FEAZELL, MALLORI (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MALLORI
Middle Name:
Last Name:FEAZELL
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 WYSTERIA LN
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-4252
Mailing Address - Country:US
Mailing Address - Phone:318-792-6770
Mailing Address - Fax:
Practice Address - Street 1:5201 SHREVEPORT HWY
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-3527
Practice Address - Country:US
Practice Address - Phone:318-640-3014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7921235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist