Provider Demographics
NPI:1871969394
Name:MALLORY, MELISSA ANN (DPT)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:MALLORY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 PERPETUAL SQ
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-1713
Mailing Address - Country:US
Mailing Address - Phone:864-342-9275
Mailing Address - Fax:
Practice Address - Street 1:107 PERPETUAL SQ
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-1713
Practice Address - Country:US
Practice Address - Phone:864-342-9275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-19
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT30655225100000X
SC7937225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist