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General NPI Number Information
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NPI Number | 1881088573
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Entity Type | Individual
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Provider Name | KELLY MALLOY
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Gender | Female
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Dates
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Enumeration Date | 03/20/2015
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Last Update Date | 03/20/2015
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Provider Practice Location Address
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Address Line | 811 W EVERGREEN AVE SUITE 306
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City | CHICAGO
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State | IL
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Zip | 60642-2682
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Country | US
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Telephone | 312-242-1665
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Fax |
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Provider Business Mailing Address
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Address Line | 10016 OLCOTT AVE
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City | SAINT JOHN
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State | IN
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Zip | 46373-9547
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251P0200X
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Taxonomy Name | Pediatric Physical Therapist
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License Number | 070021220
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License Number State | IL
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