Healthcare Provider Details

I. General information

NPI: 1619787579
Provider Name (Legal Business Name): MALLORY PUTHOFF LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2025
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 MICHIGAN ST
SIDNEY OH
45365-2401
US

IV. Provider business mailing address

11594 CONOVER RD
VERSAILLES OH
45380-8423
US

V. Phone/Fax

Practice location:
  • Phone: 937-498-2311
  • Fax:
Mailing address:
  • Phone: 937-564-7424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number33.020483
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: