Provider Demographics
NPI:1619563863
Name:WANSERSKI, MALLORY (DPT)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:WANSERSKI
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5584
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:CO
Mailing Address - Zip Code:80443-5584
Mailing Address - Country:US
Mailing Address - Phone:970-406-2559
Mailing Address - Fax:970-453-2365
Practice Address - Street 1:710 N SUMMIT BLVD UNIT 103
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:CO
Practice Address - Zip Code:80443-5666
Practice Address - Country:US
Practice Address - Phone:970-368-6908
Practice Address - Fax:970-368-6910
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15240-24225100000X
CO0017354225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist