Provider Demographics
NPI:1295188795
Name:KRKOSKA, MALLORY (MS)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:KRKOSKA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9959 BUTTONDOWN LN
Mailing Address - Street 2:
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077-8133
Mailing Address - Country:US
Mailing Address - Phone:925-451-9578
Mailing Address - Fax:
Practice Address - Street 1:6437 RUCKER RD
Practice Address - Street 2:SUITE D
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-4885
Practice Address - Country:US
Practice Address - Phone:317-405-9016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN46002979A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist