Provider Demographics
NPI:1245731991
Name:MALLERY, KATHLEEN DURGAN (OTL)
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:DURGAN
Last Name:MALLERY
Suffix:
Gender:F
Credentials:OTL
Other - Prefix:MRS
Other - First Name:KATHLEEN
Other - Middle Name:D
Other - Last Name:COUNSMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTL
Mailing Address - Street 1:22925 ROSEDALE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2490
Mailing Address - Country:US
Mailing Address - Phone:586-899-6771
Mailing Address - Fax:
Practice Address - Street 1:468 CADIEUX RD
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48230-1507
Practice Address - Country:US
Practice Address - Phone:313-473-1632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201001667225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5201001667Medicaid