Provider Demographics
NPI:1124888979
Name:GRUENDER, MALLORY MARIE (OTR/L)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:MARIE
Last Name:GRUENDER
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:PO BOX 601791
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1791
Mailing Address - Country:US
Mailing Address - Phone:980-302-8271
Mailing Address - Fax:980-302-8285
Practice Address - Street 1:2711 RANDOLPH RD STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-2027
Practice Address - Country:US
Practice Address - Phone:980-302-8271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-20
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC16635225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist