Provider Demographics
NPI:1083299655
Name:MCCOY, MALLORY SHEA
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:SHEA
Last Name:MCCOY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2209 PRIMROSE TRL
Mailing Address - Street 2:
Mailing Address - City:MELISSA
Mailing Address - State:TX
Mailing Address - Zip Code:75454-2721
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4800 US 377
Practice Address - Street 2:BUILDING #400
Practice Address - City:KRUGERVILLE
Practice Address - State:TX
Practice Address - Zip Code:76227
Practice Address - Country:US
Practice Address - Phone:940-488-5110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-15
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX121623225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist