Provider Demographics
NPI:1144762600
Name:LORENCE, MALLORY ANN (MS, AT)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:ANN
Last Name:LORENCE
Suffix:
Gender:F
Credentials:MS, AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8784 STATE ROUTE 44
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-9785
Mailing Address - Country:US
Mailing Address - Phone:330-802-1721
Mailing Address - Fax:
Practice Address - Street 1:3975 EMBASSY PKWY
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44333-8320
Practice Address - Country:US
Practice Address - Phone:330-668-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-14
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT0053882255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer