Provider Demographics
NPI:1982063749
Name:TITTLE, MALLORI (MS, ATC)
Entity Type:Individual
Prefix:
First Name:MALLORI
Middle Name:
Last Name:TITTLE
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6254 WARM SPRINGS RD APT G6
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-9152
Mailing Address - Country:US
Mailing Address - Phone:706-887-1182
Mailing Address - Fax:
Practice Address - Street 1:6254 WARM SPRINGS RD APT G6
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-9152
Practice Address - Country:US
Practice Address - Phone:706-887-1182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-22
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT002401171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider