Provider Demographics
NPI:1720844038
Name:GRANGER, MALLORY (OTR/L)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:GRANGER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 LOUISE WALDING CT
Mailing Address - Street 2:
Mailing Address - City:MIDLAND CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36350-7427
Mailing Address - Country:US
Mailing Address - Phone:334-596-1824
Mailing Address - Fax:
Practice Address - Street 1:205 GRACELAND DR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-7347
Practice Address - Country:US
Practice Address - Phone:334-793-2237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6297225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist