Provider Demographics
NPI:1851837389
Name:MALLINGER, MATTHEW LEE (BS, ATC, OTC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LEE
Last Name:MALLINGER
Suffix:
Gender:M
Credentials:BS, ATC, OTC
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:8100 W 78TH ST STE 230
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55439-2570
Mailing Address - Country:US
Mailing Address - Phone:952-946-9777
Mailing Address - Fax:952-946-9888
Practice Address - Street 1:2805 CAMPUS DR STE 465
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-2680
Practice Address - Country:US
Practice Address - Phone:952-946-9777
Practice Address - Fax:952-946-9888
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-08
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN20000272562255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer