Provider Demographics
NPI:1902248925
Name:MALONE, PHILLIP (LMT)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:
Last Name:MALONE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PETERBOROUGH
Mailing Address - State:NH
Mailing Address - Zip Code:03458-2419
Mailing Address - Country:US
Mailing Address - Phone:503-395-8522
Mailing Address - Fax:
Practice Address - Street 1:69 MAIN ST
Practice Address - Street 2:
Practice Address - City:PETERBOROUGH
Practice Address - State:NH
Practice Address - Zip Code:03458-2419
Practice Address - Country:US
Practice Address - Phone:503-395-8522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-18
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19668225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist