Provider Demographics
NPI:1417446188
Name:MALLOY, REGINA MARIE (PT)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:MARIE
Last Name:MALLOY
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 1:53370 AVENIDA MENDOZA
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-5403
Mailing Address - Country:US
Mailing Address - Phone:760-895-5145
Mailing Address - Fax:442-300-2652
Practice Address - Street 1:53370 AVENIDA MENDOZA
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-5403
Practice Address - Country:US
Practice Address - Phone:760-895-5145
Practice Address - Fax:442-300-2652
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT37560225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist