Provider Demographics
NPI:1174077663
Name:BERBERICH, MALLORY G (DPT)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:G
Last Name:BERBERICH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:G
Other - Last Name:MCGOWAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11711 NE 12TH ST
Mailing Address - Street 2:STE 3A
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-2461
Mailing Address - Country:US
Mailing Address - Phone:916-858-0950
Mailing Address - Fax:
Practice Address - Street 1:801 AUBURN WAY N STE E
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-4164
Practice Address - Country:US
Practice Address - Phone:253-736-2340
Practice Address - Fax:253-736-2343
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT291643208100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation