=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255738837
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MALLORI CROCKETT ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2014
-----------------------------------------------------
Last Update Date | 12/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 6TH AVE BOX 870308
-----------------------------------------------------
City | TUSCALOOSA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35487-1409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-348-5832
-----------------------------------------------------
Fax | 205-348-9770
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 801 6TH AVE BOX 870308
-----------------------------------------------------
City | TUSCALOOSA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35487-1409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-348-3607
-----------------------------------------------------
Fax | 205-348-4419
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 1537
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 1537
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------