Provider Demographics
NPI:1609159102
Name:HALTERMAN, MALLORY DENMARK (MHS, OTR/L)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:DENMARK
Last Name:HALTERMAN
Suffix:
Gender:F
Credentials:MHS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 BASTON RD
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-2906
Mailing Address - Country:US
Mailing Address - Phone:706-447-8700
Mailing Address - Fax:706-447-8701
Practice Address - Street 1:3648 WALTON WAY EXT
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6660
Practice Address - Country:US
Practice Address - Phone:706-434-0799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT005319225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist