Provider Demographics
NPI:1144373796
Name:EVEN, MALLORY REXROAD (MT-BC)
Entity type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:REXROAD
Last Name:EVEN
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3316 CAMERON TRL
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-3372
Mailing Address - Country:US
Mailing Address - Phone:404-579-8070
Mailing Address - Fax:
Practice Address - Street 1:3316 CAMERON TRL
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-3372
Practice Address - Country:US
Practice Address - Phone:404-579-8070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
08015225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist