Healthcare Provider Details

I. General information

NPI: 1306621529
Provider Name (Legal Business Name): MALLORY WOHLFORD PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5648 LAKE MURRAY BLVD
LA MESA CA
91942-1929
US

IV. Provider business mailing address

5648 LAKE MURRAY BLVD
LA MESA CA
91942-1929
US

V. Phone/Fax

Practice location:
  • Phone: 619-464-1352
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number304706
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: