Healthcare Provider Details

I. General information

NPI: 1124845698
Provider Name (Legal Business Name): MALLORY A GEOGHEGAN OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2024
Last Update Date: 09/25/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2171 BRIDGEPORT DR
HAMILTON OH
45013-5193
US

IV. Provider business mailing address

400 N ERIE HWY
HAMILTON OH
45011-4263
US

V. Phone/Fax

Practice location:
  • Phone: 513-868-5580
  • Fax:
Mailing address:
  • Phone: 513-887-3710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT013042
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: