Healthcare Provider Details

I. General information

NPI: 1932532660
Provider Name (Legal Business Name): BRADY MALLOY PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2013
Last Update Date: 12/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 S 13TH ST
LIVINGSTON MT
59047-3727
US

IV. Provider business mailing address

504 S 13TH ST
LIVINGSTON MT
59047-3727
US

V. Phone/Fax

Practice location:
  • Phone: 406-222-7231
  • Fax: 406-222-2435
Mailing address:
  • Phone: 406-222-3541
  • Fax: 406-823-6287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1688 PT
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: