Provider Demographics
NPI:1104340769
Name:KELLY, MALLORY A (PT, DPT)
Entity type:Individual
Prefix:MISS
First Name:MALLORY
Middle Name:A
Last Name:KELLY
Suffix:
Gender:
Credentials:PT, DPT
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:A
Other - Last Name:EPPING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 N LAKE AVE
Practice Address - Street 2:
Practice Address - City:TWIN LAKES
Practice Address - State:WI
Practice Address - Zip Code:53181-9436
Practice Address - Country:US
Practice Address - Phone:262-877-2124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-26
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100093769Medicaid