Provider Demographics
NPI:1922898212
Name:MAZE, MALLORY MORGAN (NCSP)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:MORGAN
Last Name:MAZE
Suffix:
Gender:F
Credentials:NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 MANOR DR
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:IN
Mailing Address - Zip Code:47274-2218
Mailing Address - Country:US
Mailing Address - Phone:812-525-8423
Mailing Address - Fax:
Practice Address - Street 1:510 MANOR DR
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-2218
Practice Address - Country:US
Practice Address - Phone:812-525-8423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-09
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10322524103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool