Healthcare Provider Details

I. General information

NPI: 1497393698
Provider Name (Legal Business Name): MALLORY CHICK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2019
Last Update Date: 05/19/2021
Certification Date: 05/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 W ALAMEDA AVE
BURBANK CA
91506-2932
US

IV. Provider business mailing address

1400 VETERANS BLVD
REDWOOD CITY CA
94063-2612
US

V. Phone/Fax

Practice location:
  • Phone: 818-953-4444
  • Fax:
Mailing address:
  • Phone: 650-299-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT297686
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: