Provider Demographics
NPI:1184193377
Name:GILLESPIE, MALLORY (PT)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:GILLESPIE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:398 CAMINO GARDENS BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-5827
Mailing Address - Country:US
Mailing Address - Phone:561-392-3341
Mailing Address - Fax:
Practice Address - Street 1:4383 NORTHLAKE BLVD STE 309
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-6253
Practice Address - Country:US
Practice Address - Phone:561-775-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-16
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL34123225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist