Provider Demographics
NPI:1700468618
Name:MALLORY, DEJANIRA BREONA (OTR)
Entity Type:Individual
Prefix:MRS
First Name:DEJANIRA
Middle Name:BREONA
Last Name:MALLORY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5350 AMESBURY DR APT 315
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-3408
Mailing Address - Country:US
Mailing Address - Phone:682-556-6964
Mailing Address - Fax:
Practice Address - Street 1:8550 CADENZA LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75228-4923
Practice Address - Country:US
Practice Address - Phone:214-328-4309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX121494225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist