Provider Demographics
NPI:1851814776
Name:KOVAL, MALLORY YVONNE (COTA)
Entity Type:Individual
Prefix:MISS
First Name:MALLORY
Middle Name:YVONNE
Last Name:KOVAL
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 1:97 BUTTON RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:NY
Mailing Address - Zip Code:12188-1211
Mailing Address - Country:US
Mailing Address - Phone:518-698-4548
Mailing Address - Fax:
Practice Address - Street 1:25 ADAMS RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:MA
Practice Address - Zip Code:01267-2928
Practice Address - Country:US
Practice Address - Phone:413-458-2111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-23
Last Update Date:2017-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009348-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant