Provider Demographics
NPI:1023424918
Name:MALLON, KATIE (LMT)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:MALLON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:742 N MARKET ST STE D
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1079
Mailing Address - Country:US
Mailing Address - Phone:314-740-2172
Mailing Address - Fax:
Practice Address - Street 1:742 N MARKET ST STE D
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1079
Practice Address - Country:US
Practice Address - Phone:314-740-2172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-11
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.007281225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist