Provider Demographics
NPI:1689410383
Name:RILEY, MALLORY JOYCE (LMT)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:JOYCE
Last Name:RILEY
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 1:610 S KENYON DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-4647
Mailing Address - Country:US
Mailing Address - Phone:520-548-3490
Mailing Address - Fax:
Practice Address - Street 1:7350 E 22ND ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-6427
Practice Address - Country:US
Practice Address - Phone:520-771-8389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-07140225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty