Healthcare Provider Details

I. General information

NPI: 1013832518
Provider Name (Legal Business Name): MALLORY FONTENOT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2106 RUE SIMONE
HAMMOND LA
70403-5728
US

IV. Provider business mailing address

1776 CONTINENTAL DR UNIT 1117
COVINGTON LA
70433-7289
US

V. Phone/Fax

Practice location:
  • Phone: 985-662-5448
  • Fax:
Mailing address:
  • Phone: 985-662-5448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number348438
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: