Provider Demographics
NPI:1619523826
Name:NEW, MALLORY
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:NEW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5511 PARMALEE GULCH RD # 211
Mailing Address - Street 2:
Mailing Address - City:INDIAN HILLS
Mailing Address - State:CO
Mailing Address - Zip Code:80454-4495
Mailing Address - Country:US
Mailing Address - Phone:706-851-7176
Mailing Address - Fax:
Practice Address - Street 1:1390 S POTOMAC ST STE 114
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-4529
Practice Address - Country:US
Practice Address - Phone:303-745-6717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-13
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT34882225100000X
COPTL.0018035225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT34882OtherSTATE LICENSE NUMBER