Provider Demographics
NPI:1629836259
Name:TRUMBULL, MALLORY (OTR)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:TRUMBULL
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7525 W STONEY CREEK ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-7770
Mailing Address - Country:US
Mailing Address - Phone:218-639-7546
Mailing Address - Fax:
Practice Address - Street 1:1305 W 18TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-0401
Practice Address - Country:US
Practice Address - Phone:605-333-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-08
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
508757225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist