Basic Information
| Provider Information | |||||||||
| NPI: | 1205087988 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROGDON | ||||||||
| FirstName: | MALLORY | ||||||||
| MiddleName: | LOUISE | ||||||||
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| Credential: | MHPP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2400 S. 48TH STREET | ||||||||
| Address2: | |||||||||
| City: | SPRINGDALE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797502020 | ||||||||
| FaxNumber: | 4797508967 | ||||||||
| Practice Location | |||||||||
| Address1: | 2508 SE 20TH STREET | ||||||||
| Address2: | |||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797502020 | ||||||||
| FaxNumber: | 4797508967 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2008 | ||||||||
| LastUpdateDate: | 05/24/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101Y00000X | AR | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.