Provider Demographics
NPI:1932920816
Name:GRAVES, MALLORY JOYCE (LMT)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:JOYCE
Last Name:GRAVES
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6405 SW PROSPECT CT
Mailing Address - Street 2:
Mailing Address - City:ALOHA
Mailing Address - State:OR
Mailing Address - Zip Code:97078-4318
Mailing Address - Country:US
Mailing Address - Phone:480-227-2486
Mailing Address - Fax:
Practice Address - Street 1:18565 W BASELINE RD STE A
Practice Address - Street 2:
Practice Address - City:ALOHA
Practice Address - State:OR
Practice Address - Zip Code:97006-2942
Practice Address - Country:US
Practice Address - Phone:503-352-4378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24867225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist