Provider Demographics
NPI:1073387577
Name:PEAVY, MALLORY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:PEAVY
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 1:305 IDLE PINES DR
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:GA
Mailing Address - Zip Code:31069-2338
Mailing Address - Country:US
Mailing Address - Phone:478-972-8480
Mailing Address - Fax:
Practice Address - Street 1:22 HAYES ST
Practice Address - Street 2:
Practice Address - City:TOCCOA
Practice Address - State:GA
Practice Address - Zip Code:30577-2696
Practice Address - Country:US
Practice Address - Phone:706-886-3883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT890023225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist