Provider Demographics
NPI:1396146403
Name:MOORE, MALLORY (PT,DPT)
Entity type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:
Last Name:MOORE
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 1:4668 PEMBROKE BLVD STE 115
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-6423
Mailing Address - Country:US
Mailing Address - Phone:757-648-8562
Mailing Address - Fax:
Practice Address - Street 1:100 CROFTON PL
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:VA
Practice Address - Zip Code:22963-3300
Practice Address - Country:US
Practice Address - Phone:434-589-9588
Practice Address - Fax:434-589-4096
Is Sole Proprietor?:No
Enumeration Date:2014-09-08
Last Update Date:2018-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305210720225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist