Provider Demographics
NPI:1255903449
Name:VINCENT, MALLORY (OTR)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:VINCENT
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:
Other - Last Name:BABIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:115 NEWSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:BROUSSARD
Mailing Address - State:LA
Mailing Address - Zip Code:70518-4987
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 NEWSHIRE DR
Practice Address - Street 2:
Practice Address - City:BROUSSARD
Practice Address - State:LA
Practice Address - Zip Code:70518-4987
Practice Address - Country:US
Practice Address - Phone:337-534-8978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-15
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA225X00000X
LA328058225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist