Provider Demographics
NPI:1336979723
Name:GOTT, MALLORY CAROLYN-BURCHILL (PT, DPT)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:CAROLYN-BURCHILL
Last Name:GOTT
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:895 PORTLAND RD
Mailing Address - Street 2:
Mailing Address - City:SACO
Mailing Address - State:ME
Mailing Address - Zip Code:04072-9673
Mailing Address - Country:US
Mailing Address - Phone:207-439-5104
Mailing Address - Fax:
Practice Address - Street 1:895 PORTLAND RD
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-9673
Practice Address - Country:US
Practice Address - Phone:207-439-5104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME6893225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist