Healthcare Provider Details

I. General information

NPI: 1801025986
Provider Name (Legal Business Name): LARHONDA MALLORY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2009
Last Update Date: 07/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

917 BEVILLE RD SUITE G
SOUTH DAYTONA FL
32119-1712
US

IV. Provider business mailing address

714A N WARNOCK ST
PHILADELPHIA PA
19123-1973
US

V. Phone/Fax

Practice location:
  • Phone: 800-330-7711
  • Fax: 866-426-2811
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number19123
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: