Provider Demographics
NPI:1033316872
Name:MALITO, GINA ANNE (MOT, OTRL)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:ANNE
Last Name:MALITO
Suffix:
Gender:F
Credentials:MOT, OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1312 W 38TH PL
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52806-5503
Mailing Address - Country:US
Mailing Address - Phone:563-940-4710
Mailing Address - Fax:
Practice Address - Street 1:1377 11TH ST NW
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-5068
Practice Address - Country:US
Practice Address - Phone:563-241-4230
Practice Address - Fax:563-241-4235
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001832225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI20672OtherMEDICARE
IA0665711Medicaid
IA58204OtherBLUE CROSS BLUE SHIELD
IAI20672Medicare PIN