Provider Demographics
NPI:1982163077
Name:POLITO, MALLORY
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:POLITO
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 1:189 DINNER BELL OHIOPYLE RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15437-1372
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:891 DORSEY HOTEL RD
Practice Address - Street 2:
Practice Address - City:GRANTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21536-1369
Practice Address - Country:US
Practice Address - Phone:301-895-5194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD08608225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist