Provider Demographics
NPI:1003608324
Name:RICHERT, MALLORY (PSYD)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:RICHERT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2375 SIR BARTON WAY APT 2312
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-2568
Mailing Address - Country:US
Mailing Address - Phone:402-480-0216
Mailing Address - Fax:402-480-0216
Practice Address - Street 1:220 ABRAHAM FLEXNER WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3826
Practice Address - Country:US
Practice Address - Phone:502-582-7484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-21
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY295748103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist