Provider Demographics
NPI:1144795089
Name:COTTAM, MALLORY A (PTA)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:A
Last Name:COTTAM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:A
Other - Last Name:STUCKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:200 W DOUGLAS AVE STE 1040
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67202-3017
Mailing Address - Country:US
Mailing Address - Phone:316-263-0003
Mailing Address - Fax:316-263-1241
Practice Address - Street 1:3730 N RIDGE RD STE 500
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-1233
Practice Address - Country:US
Practice Address - Phone:316-440-4901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1403422225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant