Provider Demographics
NPI:1306897905
Name:MALLALIEU, MICHELLE MARY (MSPT, CLT)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:MARY
Last Name:MALLALIEU
Suffix:
Gender:F
Credentials:MSPT, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1811 GORMLEY AVE
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-3008
Mailing Address - Country:US
Mailing Address - Phone:516-992-2864
Mailing Address - Fax:
Practice Address - Street 1:101 SAINT ANDREWS LN
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-2254
Practice Address - Country:US
Practice Address - Phone:516-674-7571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026129225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY113591255Medicare UPIN