Provider Demographics
NPI:1346641784
Name:MALLOY, BRETT ALLEN (PT)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:ALLEN
Last Name:MALLOY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-285-6647
Practice Address - Street 1:1130 N CHURCH ST
Practice Address - Street 2:STE 201
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1038
Practice Address - Country:US
Practice Address - Phone:336-375-4263
Practice Address - Fax:336-275-2286
Is Sole Proprietor?:No
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15206225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist