MEDICARE: DIVYA MALLAR PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT00009837	WA

General Provider Information

NPI Number	:	1952360315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIVYA MALLAR PT

Provider Business Mailing Address
First Line	:	790 REMINGTON BLVD
Second Line	:
City	:	BOLINGBROOK
State	:	IL
Zip	:	60440-4909
Country	:	US
Telephone Number	:	630-296-2223
Fax Number	:	630-759-9510

Provider Business Practice Location Address
First Line	:	1750 112TH AVE NE
Second Line	:	BLDG 4, STE E175
City	:	BELLEVUE
State	:	WA
Zip	:	98004-3752
Country	:	US
Telephone Number	:	425-289-0381
Fax Number	:	425-239-0387

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2006
Last Update Date	:	03/24/2017

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Directions to “ DIVYA MALLAR PT” Practice Location

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