Provider Demographics
NPI:1376033357
Name:VIG, MALLORY ALICE (OTR)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:ALICE
Last Name:VIG
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:ALICE
Other - Last Name:MANECKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 300
Mailing Address - Street 2:
Mailing Address - City:FOSSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56542-0300
Mailing Address - Country:US
Mailing Address - Phone:218-435-1210
Mailing Address - Fax:
Practice Address - Street 1:103 W 1ST ST
Practice Address - Street 2:
Practice Address - City:FOSSTON
Practice Address - State:MN
Practice Address - Zip Code:56542
Practice Address - Country:US
Practice Address - Phone:218-431-0009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist