Provider Demographics
NPI:1689566184
Name:MALLORY, LATASHA TENE
Entity type:Individual
Prefix:
First Name:LATASHA
Middle Name:TENE
Last Name:MALLORY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 S 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-1530
Mailing Address - Country:US
Mailing Address - Phone:708-227-5159
Mailing Address - Fax:
Practice Address - Street 1:303 E WACKER DR STE 1127
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-5215
Practice Address - Country:US
Practice Address - Phone:312-736-1776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-18
Last Update Date:2025-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1800050201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical