Healthcare Provider Details

I. General information

NPI: 1407764160
Provider Name (Legal Business Name): MALLORY DEMING
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9301 N 76TH ST
MILWAUKEE WI
53223-1074
US

IV. Provider business mailing address

N143W6487 LAYTON ST APT 2
CEDARBURG WI
53012-3010
US

V. Phone/Fax

Practice location:
  • Phone: 414-355-9300
  • Fax:
Mailing address:
  • Phone: 217-242-9622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number7358
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: