Provider Demographics
NPI:1710264833
Name:GROGAN, MALLORY ELIZABETH (CMT)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:ELIZABETH
Last Name:GROGAN
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 GEARY BLVD
Mailing Address - Street 2:APT 203
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109-6845
Mailing Address - Country:US
Mailing Address - Phone:707-508-7449
Mailing Address - Fax:
Practice Address - Street 1:141 BRANNAN ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94107-2004
Practice Address - Country:US
Practice Address - Phone:415-529-2762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15659225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist