Provider Demographics
NPI:1134316102
Name:MALLORY, SALLY SUE (PT; ATP)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:SUE
Last Name:MALLORY
Suffix:
Gender:F
Credentials:PT; ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4020 BOBBIN LN
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3103
Mailing Address - Country:US
Mailing Address - Phone:214-763-9173
Mailing Address - Fax:
Practice Address - Street 1:4020 BOBBIN LN
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-3103
Practice Address - Country:US
Practice Address - Phone:214-763-9173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-03
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1021103225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX247200000XMedicaid