Provider Demographics
NPI:1598008336
Name:MALLONEE, KIM J (COTA)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:J
Last Name:MALLONEE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 DIECKMAN RD
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-9614
Mailing Address - Country:US
Mailing Address - Phone:360-748-3384
Mailing Address - Fax:
Practice Address - Street 1:179 DIECKMAN RD
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-9614
Practice Address - Country:US
Practice Address - Phone:360-748-3384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-29
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC 00000505224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant