Provider Demographics
NPI:1356600407
Name:CROSIER, MALLORY (MOT)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:CROSIER
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 NW 39TH EXPRESSWAAY
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:OK
Mailing Address - Zip Code:73008
Mailing Address - Country:US
Mailing Address - Phone:405-440-9866
Mailing Address - Fax:405-440-6747
Practice Address - Street 1:6800 NW 39TH EXPRESSWAAY
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008
Practice Address - Country:US
Practice Address - Phone:405-440-9866
Practice Address - Fax:405-440-6747
Is Sole Proprietor?:No
Enumeration Date:2012-05-10
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1726225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200428880AMedicaid