Provider Demographics
NPI:1386889475
Name:MCBREEN, MALLORY (COTA)
Entity type:Individual
Prefix:MISS
First Name:MALLORY
Middle Name:
Last Name:MCBREEN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:353 1ST ST
Mailing Address - Street 2:
Mailing Address - City:PORT CARBON
Mailing Address - State:PA
Mailing Address - Zip Code:17965-1637
Mailing Address - Country:US
Mailing Address - Phone:570-292-1063
Mailing Address - Fax:
Practice Address - Street 1:2200 1ST AVE
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-2065
Practice Address - Country:US
Practice Address - Phone:570-628-6950
Practice Address - Fax:570-628-4874
Is Sole Proprietor?:No
Enumeration Date:2008-12-04
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP006641224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAOP006641OtherPENNSYLVANIA STATE LICENSE