Provider Demographics
NPI:1982826590
Name:MALLOY, KATHLEEN ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:ANN
Last Name:MALLOY
Suffix:
Gender:F
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:ELLIS INSTITUTE
Mailing Address - Street 2:9 N. EDWIN C. MOSES BLVD.
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402
Mailing Address - Country:US
Mailing Address - Phone:937-775-4341
Mailing Address - Fax:937-775-4323
Practice Address - Street 1:ELLIS INSTITUTE
Practice Address - Street 2:9 N. EDWIN C. MOSES BLVD.
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402
Practice Address - Country:US
Practice Address - Phone:937-775-4341
Practice Address - Fax:937-775-4323
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4036103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0839687Medicaid
OHCP34361Medicare PIN