Provider Demographics
NPI:1346288172
Name:MALLON, KELLY (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MALLON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 CARLISLE DR
Mailing Address - Street 2:
Mailing Address - City:IRWIN
Mailing Address - State:PA
Mailing Address - Zip Code:15642-9117
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:905 E PITTSBURGH ST
Practice Address - Street 2:SUITE E
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601-3503
Practice Address - Country:US
Practice Address - Phone:724-836-3116
Practice Address - Fax:724-836-3878
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT008642L2251N0400X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01622275Medicaid