Provider Demographics
NPI:1659835825
Name:MALLORY, MATTHEW DAVID (DPT)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:DAVID
Last Name:MALLORY
Suffix:
Gender:M
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 30516
Mailing Address - Street 2:DEPT 5300
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48909
Mailing Address - Country:US
Mailing Address - Phone:386-453-5225
Mailing Address - Fax:
Practice Address - Street 1:5570 WILSON AVE SW
Practice Address - Street 2:SUITE A
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418
Practice Address - Country:US
Practice Address - Phone:616-855-1495
Practice Address - Fax:616-855-1496
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-22
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11564225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist