Provider Demographics
NPI:1790505451
Name:MALLEO, STEPHANIE S
Entity type:Individual
Prefix:MISS
First Name:STEPHANIE
Middle Name:S
Last Name:MALLEO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 W CALIFORNIA ST STE 102
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-3445
Mailing Address - Country:US
Mailing Address - Phone:602-341-8629
Mailing Address - Fax:
Practice Address - Street 1:318 W CALIFORNIA ST STE 102
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-3445
Practice Address - Country:US
Practice Address - Phone:602-341-8629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program