Provider Demographics
NPI:1982863361
Name:MALLORY, ERIN REBECCA (MS DT)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:REBECCA
Last Name:MALLORY
Suffix:
Gender:F
Credentials:MS DT
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:REBECCA
Other - Last Name:HARTMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7420 N GREENVIEW AVE
Mailing Address - Street 2:APT. 3-S
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-1919
Mailing Address - Country:US
Mailing Address - Phone:773-381-5053
Mailing Address - Fax:
Practice Address - Street 1:7420 N GREENVIEW AVE
Practice Address - Street 2:APT. 3-S
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-1919
Practice Address - Country:US
Practice Address - Phone:773-381-5053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist