Provider Demographics
NPI:1235821679
Name:TASSEFF, MALLORY BOACKLE (PT)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:BOACKLE
Last Name:TASSEFF
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 1:1130 22ND ST S STE 1000
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-2881
Mailing Address - Country:US
Mailing Address - Phone:205-408-6600
Mailing Address - Fax:
Practice Address - Street 1:7191 CAHABA VALLEY RD STE 102
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35242-6507
Practice Address - Country:US
Practice Address - Phone:205-408-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH8787225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist