1578346607 NPI number — MS. MALLORIE PETERSON MA, PLPC

Table of content: MS. MALLORIE PETERSON MA, PLPC (NPI 1578346607)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578346607 NPI number — MS. MALLORIE PETERSON MA, PLPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
MALLORIE
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MA, PLPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PETERSON
Provider Other First Name:
MALLORIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA, PLPC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1578346607
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
523 SAPPHIRE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
O FALLON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63366-1889
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-368-2409
Provider Business Mailing Address Fax Number:
314-442-4139

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10828 SAINT CHARLES ROCK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT ANN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63074-1508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-368-2409
Provider Business Practice Location Address Fax Number:
314-442-4139
Provider Enumeration Date:
08/14/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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