Provider Demographics
NPI:1639546989
Name:ELLIOTT, MALLORY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1643 LANCASTER DR
Mailing Address - Street 2:STE 100
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-3593
Mailing Address - Country:US
Mailing Address - Phone:817-329-2524
Mailing Address - Fax:
Practice Address - Street 1:1643 LANCASTER DR
Practice Address - Street 2:STE 100
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-3593
Practice Address - Country:US
Practice Address - Phone:817-329-2524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-21
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1262776225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist