Healthcare Provider Details

I. General information

NPI: 1487524989
Provider Name (Legal Business Name): MALLORY KOCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2025
Last Update Date: 11/10/2025
Certification Date: 11/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

941 REDCLIFF RD
NEW LENOX IL
60451-3556
US

IV. Provider business mailing address

941 REDCLIFF RD
NEW LENOX IL
60451-3556
US

V. Phone/Fax

Practice location:
  • Phone: 708-670-8604
  • Fax: 202-979-7120
Mailing address:
  • Phone: 708-670-8604
  • Fax: 202-979-7120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: