Provider Demographics
NPI:1730644493
Name:DAVIS, MALLORY (ATC)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:DAVIS
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 1:315 LAKE VIEW CIR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:AL
Mailing Address - Zip Code:35135-1458
Mailing Address - Country:US
Mailing Address - Phone:205-915-7463
Mailing Address - Fax:
Practice Address - Street 1:315 LAKE VIEW CIR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:AL
Practice Address - Zip Code:35135-1458
Practice Address - Country:US
Practice Address - Phone:205-915-7463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-07
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL25432255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer