Provider Demographics
NPI:1942578505
Name:DZIURA, MALLORY (OTR/L)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:DZIURA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5783 DOMSER DR
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-1452
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 E PARK ROW
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NY
Practice Address - Zip Code:13323-1544
Practice Address - Country:US
Practice Address - Phone:315-525-5292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-09
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016938225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics