Provider Demographics
NPI:1427698752
Name:MILES, MALLORY JO
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:JO
Last Name:MILES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 GRANDVIEW DR
Mailing Address - Street 2:
Mailing Address - City:COBLESKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12043-5144
Mailing Address - Country:US
Mailing Address - Phone:518-254-3261
Mailing Address - Fax:518-254-3335
Practice Address - Street 1:178 GRANDVIEW DR
Practice Address - Street 2:
Practice Address - City:COBLESKILL
Practice Address - State:NY
Practice Address - Zip Code:12043-5144
Practice Address - Country:US
Practice Address - Phone:518-254-3261
Practice Address - Fax:518-254-3335
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043929225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist