Mallory Walters, BCBA

Primary specialty

Behavior AnalystTaxonomy code 103K00000X

License

1-22-59328 Issued in IL

Practice address

138 Field Grove CT
East Peoria, IL 61611-4323

Phone

(713) 732-7049

NPI assigned

Mar 19, 2021

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other names 1

• Mallory Nicholson Former name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1616112000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1717718400000",
    "number": "1760068803",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "138 FIELD GROVE CT",
            "city": "EAST PEORIA",
            "state": "IL",
            "postal_code": "616114323",
            "telephone_number": "713-732-7049"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "138 FIELD GROVE CT",
            "city": "EAST PEORIA",
            "state": "IL",
            "postal_code": "616114323",
            "telephone_number": "713-732-7049"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "9374 Olive Blvd Ste 101",
            "address_purpose": "LOCATION",
            "city": "Olivette",
            "state": "MO",
            "postal_code": "631323253",
            "country_code": "US",
            "telephone_number": "314-932-2402",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WALTERS",
        "first_name": "MALLORY",
        "credential": "BCBA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2021-03-19",
        "last_updated": "2024-06-07",
        "certification_date": "2024-06-07",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103K00000X",
            "taxonomy_group": "",
            "desc": "Behavior Analyst",
            "state": "IL",
            "license": "1-22-59328",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "MALLORY",
            "last_name": "NICHOLSON",
            "credential": "RBT",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Walgreen Co
• Walker Caring Hands LLC
• Christopher Walker, BA
• Walmart Inc.
• Kelsee Walsh, ATC
• Jack Glenn Walz, DDS
• Michael Christopher Walz, D.C.
• Christopher Webb, DMD
• William Greg Weinman, D.C.
• Nathan Wenzel, PHARMD, MS

• Behavior Analyst in East Peoria, IL
• Providers in East Peoria, IL by specialty
• Behavior Analyst in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 7, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.