Provider Demographics
NPI:1083100473
Name:IMOBERSTEG, MALLORY (COTA/L)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:IMOBERSTEG
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:PLATTEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53818-1146
Mailing Address - Country:US
Mailing Address - Phone:608-732-0312
Mailing Address - Fax:
Practice Address - Street 1:220 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:PLATTEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53818-1146
Practice Address - Country:US
Practice Address - Phone:608-732-0312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-09
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician