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NPI Code Detail

MEDICARE: DR. MALLORY MICHELLE GOODRICH DPT

MEDICARE: DR. MALLORY MICHELLE GOODRICH DPT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225100000XPhysical TherapistPT5484ME

General Provider Information

NPI Number : 1417507179
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. MALLORY MICHELLE GOODRICH DPT
Provider Business Mailing Address
First Line : 5 CARRIER WOOD RD APT 77
Second Line :
City : SCARBOROUGH
State : ME
Zip : 04074-7192
Country : US
Telephone Number : 207-205-2294
Fax Number :
Provider Business Practice Location Address
First Line : 561 CONGRESS ST
Second Line :
City : PORTLAND
State : ME
Zip : 04101-3308
Country : US
Telephone Number : 207-536-4968
Fax Number : 207-213-4116
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/16/2019
Last Update Date : 04/25/2024

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