Healthcare Provider Details

I. General information

NPI: 1033170048
Provider Name (Legal Business Name): ELLEN ANN MALLOY ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 WASHINGTON ST THAYER ACADEMY
BRAINTREE MA
02184-5751
US

IV. Provider business mailing address

86 JERUSALEM RD
COHASSET MA
02025-1412
US

V. Phone/Fax

Practice location:
  • Phone: 781-664-2273
  • Fax:
Mailing address:
  • Phone: 781-383-0686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAH 95
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: