Provider Demographics
NPI:1952938268
Name:KANTOS, MALLORY JANE W (OTR/L)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:JANE W
Last Name:KANTOS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:JANE
Other - Last Name:WAYTASHEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:4338 MCCOLL DR
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-1535
Mailing Address - Country:US
Mailing Address - Phone:320-250-9620
Mailing Address - Fax:
Practice Address - Street 1:2925 BUCKLEY WAY
Practice Address - Street 2:
Practice Address - City:INVER GROVE HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55076-2018
Practice Address - Country:US
Practice Address - Phone:651-455-0561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106194225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics