Basic Information
| Provider Information | |||||||||
| NPI: | 1558776013 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAGIE | ||||||||
| FirstName: | MALLORY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4041 N BROOKHOLLOW CT | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727035064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4795710334 | ||||||||
| FaxNumber: | 4797508967 | ||||||||
| Practice Location | |||||||||
| Address1: | 60 W SUNBRIDGE DR | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727031822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4796951240 | ||||||||
| FaxNumber: | 4796951242 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2014 | ||||||||
| LastUpdateDate: | 06/24/2014 | ||||||||
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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 | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.