Provider Demographics
NPI:1548688260
Name:MALLORY, MARICELA ESCAMILLA (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARICELA
Middle Name:ESCAMILLA
Last Name:MALLORY
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:PO BOX 458
Mailing Address - Street 2:
Mailing Address - City:YORKVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60560-0458
Mailing Address - Country:US
Mailing Address - Phone:630-385-2784
Mailing Address - Fax:630-553-0550
Practice Address - Street 1:520 E KENDALL DR UNIT A
Practice Address - Street 2:
Practice Address - City:YORKVILLE
Practice Address - State:IL
Practice Address - Zip Code:60560-1956
Practice Address - Country:US
Practice Address - Phone:630-385-2784
Practice Address - Fax:630-553-0550
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008795103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical