Provider Demographics
NPI:1861064396
Name:WILLIAMS, MALLORY (LMSW)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3721 N GARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74106-1519
Mailing Address - Country:US
Mailing Address - Phone:918-734-0970
Mailing Address - Fax:
Practice Address - Street 1:6028 S 66TH EAST AVE STE 103
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145-9226
Practice Address - Country:US
Practice Address - Phone:918-734-0970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7801104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK831054839Medicaid