Provider Demographics
NPI:1639869381
Name:MALLOY, CHASE L
Entity type:Individual
Prefix:
First Name:CHASE
Middle Name:L
Last Name:MALLOY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 BAGLEY RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:ME
Mailing Address - Zip Code:04950-3522
Mailing Address - Country:US
Mailing Address - Phone:207-431-5541
Mailing Address - Fax:
Practice Address - Street 1:177 VULCAN DR
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-1406
Practice Address - Country:US
Practice Address - Phone:805-733-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA307905225100000X
MEPT6514225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist