Provider Demographics
NPI:1699112615
Name:MCKUSICK, MALLOW FAY (PT)
Entity type:Individual
Prefix:
First Name:MALLOW
Middle Name:FAY
Last Name:MCKUSICK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 S PARK AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85714-1697
Mailing Address - Country:US
Mailing Address - Phone:520-889-9574
Mailing Address - Fax:
Practice Address - Street 1:4600 S PARK AVE STE 5
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85714-1697
Practice Address - Country:US
Practice Address - Phone:520-889-9574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-31
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10310225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist