Healthcare Provider Details

I. General information

NPI: 1174081350
Provider Name (Legal Business Name): FALLON MARY GOUVEIA OTR/L, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2019
Last Update Date: 01/28/2025
Certification Date: 01/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 PAOLI PIKE
MALVERN PA
19355-3311
US

IV. Provider business mailing address

2876 RINGNECK RD
AUDUBON PA
19403-1817
US

V. Phone/Fax

Practice location:
  • Phone: 484-784-7824
  • Fax:
Mailing address:
  • Phone: 484-784-7824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberO3018293
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: