Provider Demographics
NPI:1093098899
Name:PAYNE, MALLORY (OTR/L, ATC)
Entity Type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:
Last Name:PAYNE
Suffix:
Gender:F
Credentials:OTR/L, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 VILLAGE PROFESSIONAL DR N
Mailing Address - Street 2:
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801-4734
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2450 VILLAGE PROFESSIONAL DR N
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-4734
Practice Address - Country:US
Practice Address - Phone:334-528-1964
Practice Address - Fax:334-742-9352
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3257225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist