Provider Demographics
NPI:1386260602
Name:LEBOEUF, MALLORY ELYSE (PT,DPT)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:ELYSE
Last Name:LEBOEUF
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 1:983A E LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:DOWNINGTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19335-3328
Mailing Address - Country:US
Mailing Address - Phone:337-993-2766
Mailing Address - Fax:337-993-2764
Practice Address - Street 1:3013 VETERANS MEMORIAL DR STE 104
Practice Address - Street 2:
Practice Address - City:ABBEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70510-4152
Practice Address - Country:US
Practice Address - Phone:337-993-2766
Practice Address - Fax:337-993-2764
Is Sole Proprietor?:No
Enumeration Date:2020-06-23
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10639225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist