Provider Demographics
NPI:1295203339
Name:MALLARI, SHAUGN
Entity Type:Individual
Prefix:
First Name:SHAUGN
Middle Name:
Last Name:MALLARI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 ISLAND AVE
Mailing Address - Street 2:UNIT 2403
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-8244
Mailing Address - Country:US
Mailing Address - Phone:818-438-5991
Mailing Address - Fax:
Practice Address - Street 1:1212 W PARMER LN STE E
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78727-4657
Practice Address - Country:US
Practice Address - Phone:512-670-3238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA298016225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist