Provider Demographics
NPI:1336484617
Name:MALLORY, AMANDA L (DPT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:MALLORY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 NEW FIDELITY CT
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-2665
Mailing Address - Country:US
Mailing Address - Phone:919-258-2714
Mailing Address - Fax:410-648-4878
Practice Address - Street 1:1207 LIBERTY RD
Practice Address - Street 2:SUITE 106
Practice Address - City:ELDERSBURG
Practice Address - State:MD
Practice Address - Zip Code:21784-6574
Practice Address - Country:US
Practice Address - Phone:410-549-5700
Practice Address - Fax:410-549-6200
Is Sole Proprietor?:No
Enumeration Date:2012-11-28
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24267225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist