Provider Demographics
NPI:1982063749
Name:LOUGHRY, MALLORI (MS, ATC)
Entity type:Individual
Prefix:
First Name:MALLORI
Middle Name:
Last Name:LOUGHRY
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6233 CHARING DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-3733
Mailing Address - Country:US
Mailing Address - Phone:706-887-1182
Mailing Address - Fax:
Practice Address - Street 1:5065 MOYE RD # 3465
Practice Address - Street 2:
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905-5915
Practice Address - Country:US
Practice Address - Phone:706-887-1182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-22
Last Update Date:2025-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0024012255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer