Provider Demographics
NPI:1770933079
Name:LOPEZ, MALLORIE (PTA)
Entity type:Individual
Prefix:
First Name:MALLORIE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 PERKINS DR STE B
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3248
Mailing Address - Country:US
Mailing Address - Phone:575-652-3155
Mailing Address - Fax:575-652-4104
Practice Address - Street 1:1681 HICKORY LOOP
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-6502
Practice Address - Country:US
Practice Address - Phone:575-647-3773
Practice Address - Fax:575-647-3777
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant