Provider Demographics
NPI:1760082440
Name:O'MALLEY, ELIZABETH MARY (PT, DPT)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARY
Last Name:O'MALLEY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:MARY
Other - Last Name:GILLARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:235 WEALTHY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5247
Mailing Address - Country:US
Mailing Address - Phone:616-840-8000
Mailing Address - Fax:
Practice Address - Street 1:235 WEALTHY ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5247
Practice Address - Country:US
Practice Address - Phone:616-840-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-30
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501302876225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist