Provider Demographics
NPI:1134956972
Name:MALONE, LEO (OTA)
Entity type:Individual
Prefix:MR
First Name:LEO
Middle Name:
Last Name:MALONE
Suffix:
Gender:M
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 SHERWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-3520
Mailing Address - Country:US
Mailing Address - Phone:716-816-2992
Mailing Address - Fax:
Practice Address - Street 1:400 FOREST AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14213-1207
Practice Address - Country:US
Practice Address - Phone:716-816-2992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001547-01224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant