Provider Demographics
NPI:1124684758
Name:BARBER, MALLORY SUE (ATC)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:SUE
Last Name:BARBER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12598 W MEDALIST DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-6500
Mailing Address - Country:US
Mailing Address - Phone:208-954-3479
Mailing Address - Fax:
Practice Address - Street 1:12598 W MEDALIST DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-6500
Practice Address - Country:US
Practice Address - Phone:208-954-3479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-20
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer