Provider Demographics
NPI:1497339766
Name:VARNUM, MALLORY (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:VARNUM
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 VIA DEL AQUA
Mailing Address - Street 2:
Mailing Address - City:CLEWISTON
Mailing Address - State:FL
Mailing Address - Zip Code:33440-2420
Mailing Address - Country:US
Mailing Address - Phone:863-233-3846
Mailing Address - Fax:
Practice Address - Street 1:2625 E SAINT LOUIS AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-4200
Practice Address - Country:US
Practice Address - Phone:303-563-8290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist