Provider Demographics
NPI:1629714290
Name:MALLACH, SHARONA (ATC)
Entity Type:Individual
Prefix:
First Name:SHARONA
Middle Name:
Last Name:MALLACH
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 SUNSET LN
Mailing Address - Street 2:
Mailing Address - City:PAXTON
Mailing Address - State:MA
Mailing Address - Zip Code:01612-1106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 SUNSET LN
Practice Address - Street 2:
Practice Address - City:PAXTON
Practice Address - State:MA
Practice Address - Zip Code:01612-1106
Practice Address - Country:US
Practice Address - Phone:508-849-3595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-06
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA25052255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer