Provider Demographics
NPI:1811237746
Name:MALLMANN, MATTHEW (MOTR/L)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:MALLMANN
Suffix:
Gender:M
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3655 S BALDWIN RD
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48359-1506
Mailing Address - Country:US
Mailing Address - Phone:248-393-1699
Mailing Address - Fax:248-393-1711
Practice Address - Street 1:3655 S BALDWIN RD
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48359-1506
Practice Address - Country:US
Practice Address - Phone:248-393-1699
Practice Address - Fax:248-393-1711
Is Sole Proprietor?:No
Enumeration Date:2013-03-01
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL2411741225XE0001X, 225XE1200X, 225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
No225XE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistEnvironmental Modification
No225XE1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistErgonomics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI45-4940205OtherTAX ID