Healthcare Provider Details

I. General information

NPI: 1649525924
Provider Name (Legal Business Name): SUSAN MARGARET MALONEY MOT, PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2012
Last Update Date: 07/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 EDGEWORTH AVE
KIRKWOOD MO
63122-2435
US

IV. Provider business mailing address

1010 EDGEWORTH AVE
KIRKWOOD MO
63122-2435
US

V. Phone/Fax

Practice location:
  • Phone: 314-402-1634
  • Fax:
Mailing address:
  • Phone: 314-402-1634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2011027107
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License Number2011027107
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: