Provider Demographics
NPI:1700570389
Name:MALLORY, MADISON GRACE
Entity type:Individual
Prefix:MS
First Name:MADISON
Middle Name:GRACE
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 1:10999 REED HARTMAN HWY
Mailing Address - Street 2:SUITE 207
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242
Mailing Address - Country:US
Mailing Address - Phone:513-999-5506
Mailing Address - Fax:
Practice Address - Street 1:10999 REED HARTMAN HWY
Practice Address - Street 2:SUITE 207
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242
Practice Address - Country:US
Practice Address - Phone:513-999-5506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-06
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2406293.TRNE101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2910854Medicaid