Provider Demographics
NPI:1295332898
Name:NOEL, MALLORY (PT, DPT)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:NOEL
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12520 BARTON ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66213-2139
Mailing Address - Country:US
Mailing Address - Phone:870-612-4623
Mailing Address - Fax:
Practice Address - Street 1:201 S ELM AVE STE 202
Practice Address - Street 2:
Practice Address - City:EATON
Practice Address - State:CO
Practice Address - Zip Code:80615-8267
Practice Address - Country:US
Practice Address - Phone:970-454-2560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1334433225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist