Provider Demographics
NPI:1225695901
Name:SHOUKLETOVICH, MALLORY NICHOLE (MS OTR/L)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:NICHOLE
Last Name:SHOUKLETOVICH
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 HILLWOOD PRIVATE CV
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37209-2640
Mailing Address - Country:US
Mailing Address - Phone:618-889-2212
Mailing Address - Fax:
Practice Address - Street 1:3131 TOM AUSTIN HWY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:TN
Practice Address - Zip Code:37172-4801
Practice Address - Country:US
Practice Address - Phone:615-382-7979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist