Basic Information
| Provider Information | |||||||||
| NPI: | 1457097149 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAYER | ||||||||
| FirstName: | MALLORY | ||||||||
| MiddleName: | BROOKE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7721 PRIMROSE LN | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490244941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6165666051 | ||||||||
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| Practice Location | |||||||||
| Address1: | 229 E MICHIGAN AVE STE 345 | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490076403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699934373 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2022 | ||||||||
| LastUpdateDate: | 05/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801114542 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.