Provider Demographics
NPI:1992526388
Name:MATT, MALLORY (LPC)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:MATT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 YOUNG ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77611-4032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:740 YOUNG ST
Practice Address - Street 2:
Practice Address - City:BRIDGE CITY
Practice Address - State:TX
Practice Address - Zip Code:77611-4032
Practice Address - Country:US
Practice Address - Phone:409-748-0583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-18
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX86321101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional