Provider Demographics
NPI:1417930009
Name:MALLON, KEVIN FREDERICK (PHD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:FREDERICK
Last Name:MALLON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1034
Mailing Address - Street 2:(PORTLAND VAMC - HILLS CBOC)
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97207-1034
Mailing Address - Country:US
Mailing Address - Phone:503-906-5019
Mailing Address - Fax:503-906-5193
Practice Address - Street 1:1925 NW AMBERGLEN PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97006-6945
Practice Address - Country:US
Practice Address - Phone:503-906-5019
Practice Address - Fax:503-906-5193
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13735103G00000X, 103TC0700X
CAPSY 13735103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OPL137350Medicare ID - Type Unspecified