Provider Demographics
NPI:1750617460
Name:VIRGIN, MALLORY A (COTA)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:A
Last Name:VIRGIN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:A
Other - Last Name:TRICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:7300 E INDIANA ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-2794
Mailing Address - Country:US
Mailing Address - Phone:812-476-0409
Mailing Address - Fax:812-476-1016
Practice Address - Street 1:7300 E INDIANA ST
Practice Address - Street 2:SUITE 102
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-2794
Practice Address - Country:US
Practice Address - Phone:812-759-7457
Practice Address - Fax:812-759-7487
Is Sole Proprietor?:No
Enumeration Date:2009-10-30
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001704A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant