Provider Demographics
NPI:1982042461
Name:DOEDTMAN, MALLORY ANN (DPT)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:ANN
Last Name:DOEDTMAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:ANN
Other - Last Name:ALTHOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12704 E 1975TH AVE
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-6874
Mailing Address - Country:US
Mailing Address - Phone:217-821-4715
Mailing Address - Fax:
Practice Address - Street 1:12704 E 1975TH AVE
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-6874
Practice Address - Country:US
Practice Address - Phone:217-821-4715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-06
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.019727225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist