Healthcare Provider Details

I. General information

NPI: 1457974008
Provider Name (Legal Business Name): MALLORY J WILLIS DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MALLORY J WEISS

II. Dates (important events)

Enumeration Date: 05/18/2020
Last Update Date: 05/18/2020
Certification Date: 05/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S 21ST ST UNIT 130
COLORADO SPRINGS CO
80904-3763
US

IV. Provider business mailing address

600 S 21ST ST UNIT 130
COLORADO SPRINGS CO
80904-3763
US

V. Phone/Fax

Practice location:
  • Phone: 719-634-1110
  • Fax: 719-634-1112
Mailing address:
  • Phone: 719-634-1110
  • Fax: 719-634-1112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTL0016942
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: