Provider Demographics
NPI:1043018823
Name:ROOS, MALLORY (MA, PPS)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:ROOS
Suffix:
Gender:
Credentials:MA, PPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37479 AVENUE 12
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93636-8726
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36477 RUTH AVE
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93636-8512
Practice Address - Country:US
Practice Address - Phone:559-706-6167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-06
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool