Provider Demographics
NPI:1497482012
Name:STEVENS, MALLORY (LP)
Entity type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:
Last Name:STEVENS
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-9118
Mailing Address - Country:US
Mailing Address - Phone:612-767-7222
Mailing Address - Fax:
Practice Address - Street 1:721 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-9118
Practice Address - Country:US
Practice Address - Phone:651-275-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-03
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP7087103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool