Provider Demographics
NPI:1992224273
Name:KNOBLAUCH, MALLORY
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:KNOBLAUCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16633 W 45TH ST N
Mailing Address - Street 2:
Mailing Address - City:COLWICH
Mailing Address - State:KS
Mailing Address - Zip Code:67030-9455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16633 W 45TH ST N
Practice Address - Street 2:
Practice Address - City:COLWICH
Practice Address - State:KS
Practice Address - Zip Code:67030-9455
Practice Address - Country:US
Practice Address - Phone:316-208-6084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-18
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4868225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist