Provider Demographics
NPI:1376189233
Name:DAMON, MALLORY LYNN (PTA)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:LYNN
Last Name:DAMON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-9657
Mailing Address - Country:US
Mailing Address - Phone:620-639-1819
Mailing Address - Fax:
Practice Address - Street 1:510 W 7TH ST
Practice Address - Street 2:
Practice Address - City:ELLINWOOD
Practice Address - State:KS
Practice Address - Zip Code:67526-1101
Practice Address - Country:US
Practice Address - Phone:629-564-2337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1403411225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant