Provider Demographics
NPI:1174020606
Name:MALL, ALICIA (OTRL)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:MALL
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 SLATESTONE DR
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-3577
Mailing Address - Country:US
Mailing Address - Phone:989-780-4984
Mailing Address - Fax:
Practice Address - Street 1:4949 COOLIDGE HWY
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-1026
Practice Address - Country:US
Practice Address - Phone:248-655-5660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009649225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist