Provider Demographics
NPI:1154528289
Name:MALONE, KIRSTA R (OTR)
Entity type:Individual
Prefix:MRS
First Name:KIRSTA
Middle Name:R
Last Name:MALONE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MISS
Other - First Name:KIRSTA
Other - Middle Name:
Other - Last Name:ROEMMELT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:1131 KINGS CORNERS RD
Mailing Address - Street 2:
Mailing Address - City:UNION SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:13160-3193
Mailing Address - Country:US
Mailing Address - Phone:315-364-8843
Mailing Address - Fax:315-364-8016
Practice Address - Street 1:MANDEL THERAPY GROUP
Practice Address - Street 2:8842 ROUTE 90
Practice Address - City:KING FERRY
Practice Address - State:NY
Practice Address - Zip Code:13081
Practice Address - Country:US
Practice Address - Phone:315-364-7570
Practice Address - Fax:315-364-8016
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006107-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist