Provider Demographics
NPI:1497632020
Name:MALLON, NICOLE (LMT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MALLON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3886 DOUBLE BRIDGES RD
Mailing Address - Street 2:
Mailing Address - City:BATESBURG LEESVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29006-8642
Mailing Address - Country:US
Mailing Address - Phone:508-838-1422
Mailing Address - Fax:
Practice Address - Street 1:3886 DOUBLE BRIDGES RD
Practice Address - Street 2:
Practice Address - City:BATESBURG LEESVILLE
Practice Address - State:SC
Practice Address - Zip Code:29006-8642
Practice Address - Country:US
Practice Address - Phone:508-838-1422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-18
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13526225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist