1730579699 NPI number — WILLOUGHBY MIDWIFERY LLC

Table of content: MR. STEVEN MICHAEL MALLORY LPC LADC (NPI 1639244080)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730579699 NPI number — WILLOUGHBY MIDWIFERY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLOUGHBY MIDWIFERY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730579699
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1405 DR MLK JR ST N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT PETERSBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33704
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-895-2300
Provider Business Mailing Address Fax Number:
727-895-2375

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1405 DR MLK JR ST N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT PETERSBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-895-2300
Provider Business Practice Location Address Fax Number:
727-895-2375
Provider Enumeration Date:
01/30/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WILLOUGHBY
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
DARLENE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
727-895-2300

Provider Taxonomy Codes

  • Taxonomy code: 176B00000X , with the licence number:  MW289 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)