Provider Demographics
NPI:1003594680
Name:LAW, MALLORY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:LAW
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2579 CAMINO SAN PATRICIO
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-5836
Mailing Address - Country:US
Mailing Address - Phone:505-204-6082
Mailing Address - Fax:
Practice Address - Street 1:2579 CAMINO SAN PATRICIO
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-5836
Practice Address - Country:US
Practice Address - Phone:505-204-6082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT5900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist