Provider Demographics
NPI:1619277530
Name:MALLAR, KIM ALLISON (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:ALLISON
Last Name:MALLAR
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 2ND PL
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-6118
Mailing Address - Country:US
Mailing Address - Phone:516-528-1397
Mailing Address - Fax:
Practice Address - Street 1:5 2ND PL
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-6118
Practice Address - Country:US
Practice Address - Phone:516-528-1397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006958235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist