Provider Demographics
NPI:1205213451
Name:MATTEO, MALLORY
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:MATTEO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6825 BURDEN BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-5633
Mailing Address - Country:US
Mailing Address - Phone:509-416-0444
Mailing Address - Fax:509-545-1112
Practice Address - Street 1:1908 GEORGE WASHINGTON WAY STE B
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99354-2386
Practice Address - Country:US
Practice Address - Phone:509-375-1015
Practice Address - Fax:509-375-1381
Is Sole Proprietor?:No
Enumeration Date:2015-04-27
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT009674225100000X
WAPT6975244225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist